Medicaid: Eligibility for the Aged and Disabled
Congressional research reportJul 5, 2002
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Order Code RL31413
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Medicaid: Eligibility for the Aged and Disabled
Updated July 5, 2002
Julie Lynn Stone
Analyst in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress
Medicaid: Eligibility for the Aged and Disabled
Summary
Medicaid is a means-tested federal-state matching program that provides
medical assistance for persons who are unable to afford needed medical and healthrelated services. Since the program’s establishment in 1965, it has become the
largest single source of financing–both private and public–for long-term care for
those elderly and disabled who are low-income or who have depleted their income
and assets on medical and long-term care expenses. In order to be eligible for
Medicaid, individuals must meet certain eligibility criteria. These criteria are
determined by broad federal requirements and state decisions about whom they want
to cover under their Medicaid programs. The financial eligibility standards that states
do use are shaped in large part by estimates of spending that will occur with these
standards. The elderly and disabled are the most expensive groups that are covered
under Medicaid, largely because Medicaid covers nursing home and other
institutional long-term care and because this care is expensive.
Eligibility for the program’s benefits has traditionally been linked to eligibility
for cash welfare assistance; that is, a person receiving welfare assistance under
certain programs can also become eligible for Medicaid. For the elderly and disabled
groups, the cash welfare program linked to Medicaid eligibility is the Supplemental
Security Income (SSI) program. It provides federal cash welfare assistance to needy
aged, disabled and blind individuals who have little or no income and resources.
Medicaid law generally requires that states cover persons receiving SSI.
Medicaid, however, also covers elderly and disabled persons who are not poor
and who may have income in excess of SSI welfare standards. It does so through
options in Medicaid law that allow states to cover persons who need help with
medical expenses. One of these options is a medically needy program by which
states may cover persons regardless of income who incur medical expenses that
deplete their income to levels that make them needy. Medicaid also allows states to
use a higher income standard (up to 300% of basic SSI payment) for those who reside
in nursing homes or other medical care institutions or who are eligible for certain
long-term care services offered in the community. It is through these two options
that Medicaid ends up covering long-term care expenses for many non-poor elderly
persons. To make sure that persons with income and assets exceeding the welfare
standards apply their resources toward the cost of their care, Medicaid eligibility rules
include additional provisions that impose penalties on individuals who give their
assets away in order to gain Medicaid eligibility sooner than they otherwise would
and require states to recover assets from beneficiary’s estates up to amounts paid for
long-term care services after their death.
Medicaid eligibility rules also result in a diverse disabled population receiving
coverage. Many disabled persons become eligible because they cannot work and are
dependent on welfare assistance from SSI. However, Medicaid provides incentives
for other disabled persons to work and retain Medicaid coverage. The disabled
population also includes children who need a broad range of home and community
based care as well as some who need nursing home care.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Elderly and Disabled Medicaid Beneficiaries . . . . . . . . . . . . . . . . . . . . . . . . 3
Long-term Care and Other Services for the Elderly and Disabled . . . . . . . . . 4
Welfare-Related Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Coverage of Persons Receiving Supplemental Security Insurance (SSI) . . . 5
Categories of Individuals Who Qualify for SSI . . . . . . . . . . . . . . . . . . . . . . . 5
Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Adults with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Financial and Resources Eligibility Criteria . . . . . . . . . . . . . . . . . . . . . . . . . 6
Disabled Recipients Who Lose SSI Benefits . . . . . . . . . . . . . . . . . . . . . 7
Coverage of Persons in 209(b) States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Coverage of Persons Receiving State Supplemental Payments (SSP) . . . . . . 9
Combined SSI/SSP Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SSP-Only Recipients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medically Needy Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Other Aspects of Spend-Down . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Incomes up to 100% of FPL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Optional Coverage of Institutionalized Persons Under the 300% Rule . . . . . . . . 20
Miller Trusts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Optional Coverage for Persons Needing Home and Community-Based
Long-Term Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Eligibility Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Level of Care Eligibility Criteria for Institutional and Community-Based
Long-Term Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Other Mandatory and Optional Coverage Pathways . . . . . . . . . . . . . . . . . . . . . . 29
Persons Eligible for Medicare Cost-Sharing Assistance . . . . . . . . . . . . . . . 29
Qualified Medicare Beneficiary (QMB) . . . . . . . . . . . . . . . . . . . . . . . 29
Specified, Low-income Medicare Beneficiary (SLMB) . . . . . . . . . . . 30
Qualifying Individuals (QI-1 and QI-2) . . . . . . . . . . . . . . . . . . . . . . . . 30
Qualified Disabled and Working Individuals (QDWIs) . . . . . . . . . . . 30
Other Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Special Rules for Children with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Rules Applying to Disabled Individuals Engaged in Work . . . . . . . . . . . . . . . . . 32
Rules Applying to Individuals who are Homeless . . . . . . . . . . . . . . . . . . . . . . . . 34
Rules Applying to the Transfer of Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Medicaid Estate Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Rules Applying to Institutionalized Persons with Spouses Living at Home . . . . 36
Protected Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Protected Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Post-Eligibility Treatment of Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Personal Needs Allowance (PNA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Maintenance Needs Allowance for Persons Receiving Home and
Community-Based Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
List of Tables
Table 1. Medicaid Income and Resources Limits for Individuals Living in
States Using the Section 209(b) Option, November 2000 . . . . . . . . . . . . . . . 8
Table 2. Maximum Income Standard for States that Extend Medicaid to
Aged, Disabled and Blind Individuals who Receive State
Supplemental Payments and Live Independently (January 2000) . . . . . . . . 10
Table 3. States Extending Medicaid Coverage to Recipients of
Optional State Supplementary Payment-Only (SSP-Only) Groups,
as of November 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Table 4. Income Limits for Medically Needy (MNIL) and 209(b) States,
and Resources Limits for Aged, Blind, and Disabled Persons,
as of November 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 5. Special Income Rule and Miller Trusts for Institutionalized
Individuals, November 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Table 6. Pathways and Protected Income and Resources Levels Used to
Determine HCBS Waiver Program Eligibility, November 2000 . . . . . . . . . 25
Table 7. Spousal Impoverishment: State Protected Income and Resources
Amounts, November 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Table 8. Personal Needs Allowance, November 2000 . . . . . . . . . . . . . . . . . . . . 41
Table 9. Maintenance Needs Allowance and Spousal Impoverishment
Rules for HCBS, November 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Medicaid: Eligibility for the
Aged and Disabled
Introduction
Medicaid is a federal-state matching entitlement program that provides medical
assistance for certain groups of low-income individuals. The program was
established in 1965 under Title XIX of the Social Security Act and has become the
largest single source of financing – both private and public – for long-term care1 for
the elderly and disabled who are low-income or who have depleted their income and
assets on medical and long-term care expenses.2 Of the 40.3 million individuals who
were enrolled in Medicaid in fiscal year 1998 (FY98), approximately 4 million
(10.1%) qualified on the basis of being elderly and 6.9 million (17.2%) qualified on
the basis of disability.3
Although the elderly and individuals with disabilities comprise only 27.3% of
Medicaid enrollees, they command a disproportionate share of program spending.
In 1998, they accounted for 71% of the total Medicaid spending. This can be largely
attributed to Medicaid’s coverage of long-term care benefits that provide a wide-array
of institutional and community-based services not generally covered (or in some
instances only partly covered) by other public programs (such as Medicare), or
private insurance plans. Of the approximately $101 billion spent by Medicaid on
elderly and disabled individuals in 1998, more than 60% ($61.8 billion) was for longterm care. Of those dollars, 71% ($44.2 billion) was for institutional care – including
nursing facilities, intermediate care facilities for the mentally retarded and mental
health facilities, and the remaining spending 29% ($17.6 billion) was paid for home
and community-based services – including a range of services such as home health,
1
Long-term care offers a wide range of personal, social, and medical support services
through institutions and community-based programs.
2
Medicaid also plays a significant role in the provision of preventive, primary and acute
care for millions of low-income children, families and pregnant women.
3
Data prepared by Congressional Research Service (CRS) based on analysis from Health
Care Financing Administration, Form 2082. CRS Report RL30733, Medicaid Expenditures
and Enrollees, 1998, by Evelyne Baumrucker and Jean Hearne. (Hereafter cited as CRS
Report RL30733.)
CRS-2
personal care, adult day care, care coordination, home modifications, transportation
and respite for caregivers.4
Medicaid is a means-tested program intended to provide assistance to persons
who are unable to afford needed medical and health-related services. Within broad
federal guidelines, states have flexibility to determine eligibility criteria. In general,
the federal government mandates states to meet minimum eligibility standards, but
states also have a great deal of flexibility in using standards that are more generous
or more restrictive. The financial eligibility standards that states do use are shaped
in large part by estimates of spending that will occur with these standards. The
elderly and disabled are the most expensive groups that are covered under Medicaid.
In 1998, spending averaged $9,058 per disabled Medicaid beneficiary and $10,193
per elderly Medicaid beneficiary, as compared to $1,442 for children under age 21
and $2,292 for non-disabled adults.5
Eligibility for the program’s benefits has traditionally been linked to eligibility
for cash welfare program assistance; that is, a person receiving welfare assistance
under certain programs can also become automatically eligible for Medicaid. For the
elderly and disabled groups, the cash welfare program linked to Medicaid eligibility
is the Supplemental Security Income (SSI). It provides federal cash welfare
assistance to needy aged, disabled and blind individuals who have little or no income
and resources. Medicaid law generally requires that states cover persons receiving
SSI.
In addition to the SSI eligibility pathway into Medicaid, the statute includes
other provisions that allow states to extend Medicaid eligibility to other elderly and
disabled individuals. These individuals must also meet financial standards to become
eligible. Financial standards are defined as the maximum amount of income and
resources (such as cars, savings accounts, bonds, stocks and real estate) an individual
is allowed to have and still qualify for Medicaid.
Not only do states have flexibility, within broad federal guidelines, to use
specific financial standards for different eligibility groups, but they also have
flexibility in the rules they use to define income and resources. For example, when
counting an individual’s income to determine whether an individual is Medicaid
eligible, some states may count all pensions, social security payments and annuities,
but disregard $20 dollars for miscellaneous costs and $200 dollars for housing
expenses. Other states may not have such income disregards.
State flexibility has led to variation in income and resources requirements as
well as the means by which income and resources are counted across states. In
general, individuals in similar circumstances of need for medical or long-term care
4
Tables 9 and 10. Medicaid Medical Vendor Payments by Basis of Eligibility of
Beneficiaries: Fiscal Year 1998. Medicaid Statistics: Program and Financial Statistics
Fiscal Year 1998. Health Care Financing Administration, Pub. No. 10129, August 2000.
Based on data from the Health Care Financing Administration (HCFA) Form 64 reports.
5
Data prepared by CRS based on analysis from Health Care Financing Administration
Forms 64 and 2082. CRS Report RL30733.
CRS-3
may be automatically eligible for coverage in one state, but may be required to
assume a certain portion of their medical expenses before they can obtain coverage
in a second state, and not eligible at all in a third state. Statewide variation
concerning income and asset requirements, makes generalizations about eligibility
as it applies to a particular individual or the nation difficult.
A brief profile of elderly and disabled beneficiaries as well as the variety of
eligibility pathways outlined by federal law and implemented, with significant
variation, by states will be described in this report.
Elderly and Disabled Medicaid Beneficiaries
In 1998, there were approximately 10.9 million elderly and disabled Medicaid
beneficiaries across all states, comprising 27.3% of all Medicaid beneficiaries. Four
million of this number were elderly and 6.9 million were disabled. This section
presents some of their characteristics as well the acute and long-term care services
they receive through Medicaid.
The elderly are defined as persons 65 years of age and older. Demographic
projections show record rates of growth in the elderly population. In the year 2000,
the nation’s elderly population totaled approximately 34 million persons.6 This
number is expected to more than double over the next half century.7 This growth will
impose significant pressure on federal and state budgets that fund Medicaid. The
Congressional Budget Office (CBO) estimates that the federal share of Medicaid
spending will grow from 1.2% of gross domestic product (GDP) in 1999 to 3.7% in
2040, in part because of the aging of the population.8
The population of disabled Medicaid enrollees is diverse, with individuals
experiencing a variety of physical impairments (including conditions related to
vision, hearing, communication or mobility), severe mental and emotional
conditions, and functional limitations (such as bathing, dressing, eating, getting in or
out of a bed or chair, preparing meals, shopping or doing housework).9 Medicaid
covers both disabled adults and children. The blind are grouped within the category
of individuals with disabilities under the Medicaid statute.
6
Kassner, Enid and Bectel, Robert W. Midlife and Older Americans with Disabilities:
Who Gets Help? A Chartbook. The Public Policy Institute, Research Group, American
Association of Retired Persons. 1998.
7
The population age 65 to 74 is predicted to nearly double – from 18 million in 2000 to 35
million in 2050; the number of individuals age 75 to 85 will also more than double - from
12 million in 2000 to 26 million in 2050; and the population age 85 and older is expected
to more than quadruple – from 4 million in 2000 to 28 million in 2050. Projections include
institutionalized individuals (Kassner, et. al., 1998).
8
Congressional Budget Office, The Long-Term Budget Outlook, Washington, October
2000. From website, December 11, 2000:
[http://www.cbo.gov/showdoc.cfm?index=2517&sequence=0&from=7]
9
Meyer, Ph.D., Jack A., and Pamela J. Zeller, Ph.D. Profiles of Disability: Employment and
Health Coverage. Medicaid and the Uninsured. The Kaiser Commission on Medicaid and
the Uninsured, September 1999.
CRS-4
People with disabilities are more likely to be poor than individuals without
disabilities. As a result, disabled individuals are more likely to rely on Medicaid for
their health coverage than on private health insurance.10 In addition, the prevalence
of disability increases with age, with a large number of Medicaid recipients being
both disabled and elderly.
Many elderly and disabled Medicaid beneficiaries are also covered under
Medicare. Medicare is a nationwide entitlement program that provides health
insurance coverage for a defined package of services for elderly and certain disabled
individuals. When persons qualify for both Medicaid and Medicare they are
considered “dual eligibles.” Dual eligibles receive their acute care services through
Medicare and prescription drug coverage and long-term care services through
Medicaid. Medicaid also pays Medicare premium and co-pay costs for some lowincome Medicare beneficiaries.
Long-term Care and Other Services for the Elderly and
Disabled
Most aged and disabled Medicaid enrollees live in the community and rely on
Medicaid to pay for their preventive and acute care needs. There are, however, a
significant number who rely on long-term care services paid for by Medicaid. About
467,451 aged and disabled individuals received long-term care services in the
community under home and community-based waiver services (described later) and
approximately 1.8 million individuals received long-term care services while living
in institutional settings, such as nursing facilities and intermediate care facilities for
the mentally retarded.11
All states determine eligibility for long-term care services based on a test of an
applicant’s functional limitations. The design of these tests varies across states, but
often includes tests to determine an applicant’s limitations in his or her ability to
carry out activities of daily living (ADLs) and instrumental activities of daily living
(IADLs). ADLs refer to activities necessary to carry out basic human functions, and
include the following: bathing, dressing, eating, getting around inside the home,
toileting, and transferring from a bed to a chair. IADLs refer to tasks necessary for
independent community living, and include the following: shopping, light
housework, telephoning, money management, and meal preparation.
A wide variety of acute and long-term care services, targeted to the needs of
these special populations, are available under Medicaid. Federal law requires state
Medicaid programs to cover hospital, nursing facility and other primary and acute
care services. States also have the option of offering additional services, such as
10
Schneider, Andy, Victoria Strohmeyer, and Risa Elberger. Medicaid Eligibility for
Individuals with Disabilities. The Henry J. Kaiser Family Foundation, Washington D.C.
July 1999.
11
U.S. Department of Health and Human Services, Health Care Financing Administration,
Center for Medicaid and State Operations. Table 32: Medicaid Long-Term Care
Beneficiaries and Days of Care. Medicaid Statistics: Program and Financial Statistics
Fiscal Year 1998. HCFA Pub. NO. 10129. August 2000.
CRS-5
prescription drugs, long-term care services and dental care. This flexibility under
Medicaid law has led to widespread variation in state Medicaid benefit packages
offered to elderly, disabled and blind individuals across states.
Welfare-Related Pathways
Coverage of Persons Receiving Supplemental Security
Insurance (SSI)
Traditionally, Medicaid eligibility for aged and disabled individuals has been
linked to the federal welfare program, Supplemental Security Income (SSI), under
Title XVI of the Social Security Act. The SSI program is administered at the federal
level and cash benefits are reserved exclusively for the aged, disabled and blind. SSI
is a means-tested income assistance program for aged, blind and disabled individuals
who have low incomes and limited resources. In FY 2001, about 6.7 million
individuals received SSI benefits.
Generally, states are required to provide Medicaid coverage to recipients of SSI
and rely on SSI eligibility rules, established at the national level, as the basis for
Medicaid eligibility. In order 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.
Categories of Individuals Who Qualify for SSI
Elderly. The elderly, or aged, are defined as persons 65 years and older. The
aged comprised approximately 30% of the SSI recipient population in FY 2001, and
totaled approximately 2 million individuals. Because the incidence of disability
increases with age, many elderly individuals are also disabled, but in these cases, are
classified generally as elderly for Medicaid program data collection purposes.
Adults with Disabilities. Individuals with disabilities are defined under
Medicaid and SSI as those unable to engage in any substantial gainful activity (SGA)
by reason of a medically determined physical or mental impairment expected to last,
for a continuous period of at least 12 months. The test of “substantial gainful
activity” is to earn $780 monthly in counted income as of 2002, with impairmentrelated expenses subtracted from earnings. For disabled individuals who are blind
– defined as having 20/200 vision or less with the use of correcting lens in the
person’s better eye, or those with tunnel vision of 20 degrees or less – a different
SGA level applies. SGA for the blind is earnings of $1,300 a month in 2002 and is
adjusted annually to reflect growth in average wages.12 Generally, the individual
12
The passage of this provision, under P.L. 95-216 in 1977, gave rise to controversy
concerning the blind’s preferential treatment under the law. Proponents of liberalizing the
SGA amount for the blind maintain that adverse employment experiences for the blind,
including high job-related costs and unemployment, are greater than for persons who have
other disabilities. Opponents, on the other hand, argue that there are many other
(continued...)
CRS-6
must be unable to do any kind of work, that exists in the national economy, taking
into account age, education, and work experience. Individuals with disabilities aged
18 to 64 comprised the majority of SSI recipients, totaling about 57%, or
approximately 3.8 million individuals in FY 2001.
Children with Disabilities. Children may qualify for SSI if they are under
age 18 (or under age 22 if a full-time student), unmarried, and meet the applicable
SSI disability or blindness, income, and resources requirements. P.L. 104-193, the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(PRWORA), established a new disability definition for children under age 18 which
requires a child to have “a medically determinable physical or mental impairment
which results in marked and severe functional limitations, and which can be expected
to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months.” Parents’ income is considered when determining
the eligibility of children. SSI requires that some of the income of ineligible family
members (i.e., parents) be deemed available to meet the basic needs of children
before extending eligibility to those children. Individuals with disabilities under age
18 comprised about 13%, approximately 865,700 individuals, of the SSI recipient
population in FY 2001.13
Financial and Resources Eligibility Criteria
Income. An individual’s income is used to determine eligibility for SSI and
to calculate the benefit payment. Two types of income are considered: earned and
unearned. Earned income includes wages, net earnings from self-employment and
earnings from services performed. All other income (including Social Security
benefits, other government and private pensions, veteran’s benefits, workers’
compensation and in-kind support and maintenance) not derived from current work
is considered “unearned.” In an individual has income, a dollar-for-dollar reduction
is made against the maximum federal SSI benefit, which is $580 in 2002 (in 2000 the
benefit level was $512). The federal SSI benefit for a couple with both members
qualifying for SSI is $817 in 2002 (in 2000, the benefit level was $769).
Resources. In addition to income criteria, SSI limits the countable resources
persons may have in order 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. 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.
12
(...continued)
impairments that could easily be viewed as needing special compensatory relief, such as
quadriplegia, cancer, etc. For more information see CRS Report RS20479, Social Security:
Substantial Gainful Activity for the Blind, by Geoffrey Kollmann. A variety of Senate and
House bills have been proposed to modify P.L. 95-216, but none have become law.
13
Brooks, Alfreda M. Social Security Administration. Office of Policy, Office of Research,
Evaluation, and Statistics, Division of SSI Statistics and Analysis. SSI Annual Statistical
Report, 1999. June 2000.
CRS-7
Countable resources do not, however, include all resources that an individual
or couple may own. As of May 2000, they exclude, but are not limited to, the
following:
An individual’s home, of any value, as long as it is used as the
applicant’s principal place of residence;
! The first $4,500 in current market value of an auto (100% of the
auto’s value is excluded if it is equipped for use by a handicapped
person, if it is needed to go to work or to perform essential daily
activities due to distance, climate or terrain, or if it is used to obtain
regular medical treatment);
! Up to $2,000 of household goods and personal effects;
! Life insurance policies with a total face value of $1,500 or less per
person;
! Burial funds not in excess of $1,500 each for an individual and
spouse (plus accrued interest);
! Property essential to self-support, including property used in a trade
or business or on the job if the individual works for someone else;
and
! Resources set aside to fulfill a plan to achieve self-support.
!
As of September 2000, 39 states and the District of Columbia provided
Medicaid coverage to persons eligible for SSI.
Disabled Recipients Who Lose SSI Benefits. Disabled recipients who
lose federal SSI eligibility because of earnings above the substantial gainful activity
level may continue to retain eligibility for SSI and Medicaid under Section 1619 (P.L.
96-265) of the Social Security Act. For more information about these rules, see the
discussion, “Rules Applying to Disabled Individual Engaged in Work,” on page 32
below.
Coverage of Persons in 209(b) States
While 39 states and the District of Columbia extend automatic Medicaid
eligibility to persons receiving SSI, 11 states do not. These states are so-called
“209(b) states.” When SSI was enacted in 1972, certain states expected that the
number of elderly and disabled cash assistance recipients would grow significantly.
To protect states from potentially large increases in their Medicaid expenditures for
the aged and disabled populations, Section 209(b) of the Social Security
Amendments of 1972 (P.L. 92-603) gave states the option to continue using the
financial standards and definitions for disability they had in effect in January 1972
to determine Medicaid eligibility for the aged, blind, and disabled residents, rather
than making all SSI recipients automatically eligible for Medicaid.
Under the 209(b) provision, states may elect the option to use income and
resources standards that are no more restrictive than those in effect on January 1,
1972. These states may require persons to meet a lower income standard than SSI’s
or may use more restrictive policies for defining countable income. They may also
have lower limits for the amounts of resources a person may have. Each of the
209(b) states has at least one eligibility standard (income, resources, or definition of
CRS-8
disability) that is more restrictive than SSI standards. The 11 section 209(b) states
are Connecticut, Illinois, Hawaii, Indiana, Minnesota, Missouri, New Hampshire,
North Dakota, Ohio, Oklahoma and Virginia. Of these, three have income standards
below the 2000 SSI level of $512 per month, and five states use a resource threshold
lower than SSI’s standard of $2000. In other cases, a state’s standards may be the
same as SSI’s or even more liberal. It is important to note again, however, that states
count income differently. This means that persons with income levels higher than
the states’ standards, as listed in Table 1, might still be able to qualify for Medicaid.
In addition to the income standards, Table 1 shows resources standards used by the
209(b) states.
States that use more restrictive eligibility rules under section 209(b) must also
allow applicants to deduct medical expenses from the individual’s countable income
when determining eligibility. This process is sometimes referred to as the “209(b)
spend-down.” An example of 209(b) spend-down is as follows: if an applicant has
a monthly income of $700 (not including any SSI or SSP payments – described
below) 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 will be discussed later, the spend-down process
is also used in establishing eligibility for the medically needy.
Table 1. Medicaid Income and Resources Limits for Individuals
Living in States Using the Section 209(b) Option,
November 2000
Section 209(b)
eligibility
standard
(monthly
income)a
Section 209(b)
eligibility
standard (% of
FPL)b
Section 209(b)
resources limitc
More
restrictive
aspectsd
Federal SSI
Standard
$512
74%
$2,000
–
Connecticut
$564.10e
81%
$1,600
I,R
Illinois
$487
70%
$2,000
I,R
Hawaii
$512
74%
$2,000
R
Indiana
$512
74%
$1,500
I,R,D
Minnesota
$482
69%
$3,000
I,R
Missouri
$512
74%
$999.99f
I,R
New Hampshire
$526
76%
$1,500
I,R,D
North Dakota
$455
65%
$3,000
R
Ohio
$444
64%
$1,500
I,R
Oklahoma
$512
100%
$2,000
R
Virginia
$512
74%
$2,000
R
State
CRS-9
Source: Congressional Research Service Survey of Selected Medicaid Eligibility and Post-Eligibility
for Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email,
telephone and fax.
a
States using the Section 209(b) option may use different methods of counting income than SSI.
The 2000 federal poverty level (FPL) in the 48 contiguous states and the District of Columbia was
$8,350 for one person, or $696 per month. The FPL for Hawaii was $9,590 for one person, or
$800 per month. (Source: HHS Poverty Guidelines, Federal Register, v. 65, no. 31, February
15, 2000. p. 7555-7557).
c
States using the Section 209(b) option may use different methods of counting resources than SSI.
d
These are the aspects of eligibility determination that are more restrictive than the SSI program,
including: methods for counting income (states have flexibility to determine what type of income
they count as applying toward a person’s total income, as well as flexibility to determine what
type of income they will not count, and thus subtract from a person’s total income.) (I), methods
for counting assets or resources (R), and/or definitions of disability (D).
e
This amount varies by living situation.
f
$2,000 in resources are protected for blind individuals.
b
Coverage of Persons
Payments (SSP)
Receiving
State
Supplemental
Many states, recognizing that the SSI benefit standard may provide too little
income to meet an individual’s living expenses, supplement SSI with additional cash
assistance payments made solely with state funds. States use a variety of different
policies for providing these state supplemental payments (SSP) and are granted
flexibility in determining whether they will make such payments, to whom, and in
what amount.14 These supplements, paid on a regular monthly basis, are intended to
cover such items as food, shelter, clothing, utilities and other daily necessities
determined by the individual states. Supplementary payments allow a state to
provide an income “floor” that takes into account geographic differences in living
costs and individualized special needs in a manner that the nationally uniform federal
benefit standard used in SSI cannot do.
Some states provide supplemental payments to all persons who receive SSI.
Other states may decide to make payments to elderly persons living independently
in the community without special needs, while still others may require that the elderly
have special needs, such as requiring in-home personal care assistance or homedelivered meals as the result of impairment or frailty. In all of these cases, states may
extend Medicaid coverage to persons receiving SSP on the same basis as they do to
persons receiving only SSI. They may also decide to extend Medicaid eligibility to
only some groups of SSP recipients or decide to extend it to all. States are not
required to index SSP payments to inflation. As of January 2000, 27 states provide
some form of optional state supplementation to individuals living independently and
one state (North Dakota) allows its municipalities to determine whether and to whom
payments are provided.
14
Federal law prohibits those states that provide SSP from changing their payment levels
for SSP as federal SSI payments are increased to reflect cost of living. This rule was made
for the purpose of prohibiting states from lowering their SSP payments when federal SSI
payments increase as a result of adjustments based on cost of living.
CRS-10
Combined SSI/SSP Benefit. When states that provide automatic Medicaid
eligibility to persons receiving SSI provide Medicaid coverage to persons receiving
SSP, the combined federal SSI and state SSP benefit payments becomes the effective
income eligibility standard for Medicaid. For 209(b) states, however, the effective
eligibility standard is the 209(b) categorical eligibility standard plus the SSP
payment. Table 2 provides an example of what the benefit standards were, as of
January 2000, for certain persons receiving SSP payments; in this case, aged,
disabled and blind individuals living independently. The amounts listed in Table 2
indicate the maximum state supplement as well as the combined amount of income
an individual may maintain and remain eligible for Medicaid through this eligibility
pathway.15
Table 2. Maximum Income Standard for States that Extend
Medicaid to Aged, Disabled and Blind Individuals who Receive
State Supplemental Payments and Live Independently
(January 2000)
Combined SSI/ 209(b) and
SSP Income Levela
State Supplementation
Alabama
$572
$60
Alaska
874
362
Arizona
582
70
Arkansas
512
0
Californiab
692
180
Coloradoc
548
36
Connecticutd
747
235
Delaware
512
0
District of Columbia
512
0
Florida
512
0
Georgia
512
0
Hawaii
516.9
4.90
Idaho
565
53
Illinoise
717.99
351
Indiana
512
0
Iowaf
534
22
Kansas
512
0
State
15
Because specified amounts of income are disregarded in determining eligibility for SSI
and most state SSP programs, a person with income exceeding the maximum benefit may
still be eligible for cash assistance and Medicaid.
CRS-11
Combined SSI/ 209(b) and
SSP Income Levela
State Supplementation
Kentucky
512
0
Louisiana
512
0
Maine
522
10
Maryland
512
0
Massachusettsg
640.82
128.82
Michigan
526
14
Minnesotah
563
81
Mississippi
512
0
Missourii
903 (blind only)
391 (Blind only)
Montana
512
0
Nebraska
519
7
Nevadaj
548.40 (725.96 for blind)
36.40 ($213.96 for blind)
New Hampshire
553
27
New Jersey
543.25
31.25
New Mexico
512
0
New York
599
87
North Carolina
512
0
North Dakota
455
0 (an option of individual
counties)
Ohio
444
0
Oklahoma
565
53
Oregonk
513.70 ($537.70 for blind)
1.70 ($25.70 for blind)
Pennsylvania
539.40
27.40
Rhode Island
576.35
64.35
South Carolina
512
0
South Dakota
527
15 (limited to SSI recipients
with no other source of income)
Tennessee
512
0
Texas
512
0
Utah
512
0
Vermontl
569.66
57.66
Virginia
512
0
State
CRS-12
Combined SSI/ 209(b) and
SSP Income Levela
State Supplementation
Washingtonm
539
27
West Virginia
512
0
Wisconsin
595.78
83.78
Wyoming
521.90
9.90
State
Note: Some states have payment levels for the aged that differ from payment levels
to the blind and or the disabled.
Source: Social Security Administration, Office of Policy, Office of Research, Evaluation and
Statistics, Division of SSI Statistics and Analysis. State Assistance Programs for SSI Recipients,
January 2000.
a
The federal SSI benefit rates in January 2000 are included in the combined federal/state data column.
In 2000, the federal SSI benefit for an individual living independently was $512.00.
b
California’s payment amounts pertain only to aged and disabled individuals. Payments offered to
blind individuals are higher.
c
Colorado’s payment amounts pertain to aged individuals. Payments offered to blind and disabled
individuals are lower.
d
Connecticut’s amounts presented pertain to independent community living and consists of a housing
allowance (maximum of $400 for living alone; $200 for living with others), basic needs items,
minus countable income. The amounts presented assume eligibility for the highest rental
allowance and the maximum budget amount.
e
Illinois’ combined SSI and SSP payment may not exceed $717.99. Illinois also had an income
standard for categorically eligible individuals who do not qualify for SSI of $487.
f
Iowas’s payment amounts pertain only to disabled individuals. There are no benefits offered to aged
and disabled individuals living independently.
g
Massachusetts' payment amounts pertain only to aged individuals. Payments offered to blind
individuals are higher and payments offered to disabled individuals are lower.
h
Minnesota allows all persons who receive SSI payments and state supplemental payments to qualify
for Medicaid. In 2000, it also allowed persons who did not receive SSI or SSP payments, and
whose income did not exceed $482, to qualify for Medicaid.
i
Missouri provides payments only to the blind.
j
Nevada’s payment amounts pertain only to the aged. Payments offered to blind individuals are
higher. There are no payments offered to disabled individuals.
k
Oregon’s payment amounts pertain only to the aged and disabled. Payments offered to blind
individuals are higher.
l
Vermont’s payment amounts became effective as of September 1, 2000.
m
Washington’s payment amounts pertain to individuals living in the state-defined Area 1. Payments
offered to individuals living in the state-defined Area 2 are lower.
SSP-Only Recipients. States may also extend Medicaid coverage to persons
who receive only SSP. These persons must meet all SSI eligibility criteria, other than
income, and SSP must be available statewide. Thirty-six states extend optional
Medicaid coverage to some SSP-only beneficiaries. Table 3 shows those groups
covered by states (aged, blind and or disabled) that, as of November 2000, offered
Medicaid to SSP-only recipients.
CRS-13
Table 3. States Extending Medicaid Coverage to Recipients of
Optional State Supplementary Payment-Only (SSP-Only)
Groups, as of November 2000
States choosing
Medicaid
coverage for SSPonly groups
SSP-only recipients
living independentlya
SSP-only recipients
living in group
arrangementsb
Alabama
no
–
–
Alaska
yes
A,B,D
A,B,D
Arizona
no
–
–
Arkansas
no
–
–
California
yes
A,B,D
A,B,D
Colorado
yes
A
A
Connecticut
yes
A,B,D
A,B,D
Delaware
yes
–
A,B,D
District of Columbia
yes
–
A,B,Dc
Florida
no
–
–
Georgia
no
–
–
Hawaii
yes
A,B,D
A,B,D
Idaho
yes
A,B,D
A,B,D
Illinois
yes
A,B,D
A,B,D
Indiana
no
–
–
Iowa
yes
A,B,D
A,B,D
Kansas
no
–
–
Kentucky
yes
A,B,Dd
A,B,D
Louisiana
no
–
–
Maine
yes
A,B,D
A,B,D
Maryland
yes
–
A
Massachusetts
yes
A,B,D
A,B,D
Michigan
yes
A,B,D
–
Minnesota
yes
A,B,D
A,B,D
Mississippi
no
–
–
Missouri
yes
B
A,B,D
Montana
yes
–
D
State
CRS-14
States choosing
Medicaid
coverage for SSPonly groups
SSP-only recipients
living independentlya
SSP-only recipients
living in group
arrangementsb
Nebraska
yes
A,B,D
A,B,D
Nevada
yes
A,B
A,B
New Hampshire
yes
A,B,D
A,B,D
New Jersey
yes
A,B,D
A,B,D
New Mexico
no
–
–
New York
yes
A,B,D
A,B,D
North Carolina
yes
–
A,B,D
North Dakota
no
–
–
Ohio
yes
–
A,B,D
Oklahoma
yes
A,B,D
A,B,D
Oregon
yes
A,B,D
A,B,D
Pennsylvania
yes
A,B,D
A,B,D
Rhode Island
yes
A,B,D
A,B,D
South Carolina
yes
–
A,B,D
South Dakota
yes
A,B,D
A,B,D
Tennessee
no
–
–
Texas
no
–
–
Utah
yes
A,B,D
A,B,D
Vermont
yes
A,B,D
A,B,D
Virginia
yes
–
A,B,D
Washington
yes
A,B,D
A,B,D
West Virginia
no
–
–
Wisconsin
yes
A,B,D
A,B,D
Wyoming
no
–
–
State
Source: Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email, telephone
and fax.
a
A=aged, B=blind and D=disabled; state supplement available if living independently, such as living
alone.
b
A=aged, B=blind and D=disabled; State supplement available only if living in group environment,
such as an adult foster home or group home.
c
State supplement available only if living in community residential facilities.
d
State supplement available only if receiving care-taker services.
CRS-15
Medically Needy Coverage
In addition to welfare-related pathways, Medicaid also provides states the option
of covering elderly and disabled persons who are not poor by SSI or SSP standards,
but who need assistance with medical care expenses. Under the medically needy
pathway, individuals who live in a state that exercises the medically needy option can
qualify for Medicaid if they have income and resources that exceed the standards
established by the states for the medically needy programs, but only if they incur
medical expenses that “spend-down” or deplete their income and resources to
specified levels.
Spend-down refers to a process by which persons with income above the
applicable limit, may reduce their income to the state limit by spending on medical
care.16 This process is similar to the spend-down process used in 209(b) states. For
example, if an individual has monthly income of $600 and the state’s medically
needy income standard is $300, the applicant would be required to incur $300 in
medical expenses (i.e., spend-down) before he or she would be eligible for Medicaid.
Once Medicaid eligibility is triggered, beneficiaries must still apply their income
toward the cost of their medical care.
The state may set its medically needy monthly income limits (MNIL) for a
family of a given size at any level up to 133% of the maximum payment for a similar
family under the state’s AFDC program in place on July 16, 1996.17 Often these
levels are lower than the income standard for SSI benefits. In 11 states, the spenddown limits are less than 50% of the federal poverty level (FPL) for an individual.
The spend-down limits range from $92 in Louisiana18 to $708 in Vermont. This, in
effect, is an income threshold for Medicaid eligibility. It also represents, for persons
living in the community, the amount of monthly income individuals may retain for
their needs after incurring medical expenses that deplete their income to the state
standard. Although there is some variation across states, most states use the SSI
resources limit of $2,000 for an individual as the medically needy resources standard.
16
Medical expenses that are considered when calculating an applicant’s spend-down include
certain medical and remedial care expenses incurred by an individual, family or financially
responsible relative that are not subject to payment by a third party unless the third party is
a public program of a state (or territory) or political subdivision of a state (or territory).
Some insurance premiums, deductibles or coinsurance charges (including Medicare
premiums and cost sharing charges for persons eligible for both programs) can also be
deducted from countable income.
17
In effect as of May 11, 2001, HCFA regulation (42 CFR Part 435) will increase state
flexibility in establishing the income disregards used to determine eligibility under
Medicaid’s medically needy pathway. The new regulation will allow states to apply more
liberal income disregards under Section 1902(r)(2) of the Social Security Act, thus
increasing the amount of protected income medically needy eligibles can retain to pay for
such things as food, clothing or housing. Whereas the income standard for a family of a
given size could still not exceed 133% of the maximum payment for a similar family under
the state’s maximum AFDC payment (described above), states could in effect enable
applicants to keep more income to spend on housing, food, transportation, etc.
18
The MNIL standard varies by geographic region in Louisiana.
CRS-16
State monthly income and resources limits for medically needy programs are shown
in Table 4. Note that some 209(b) states have medically needy programs.
States that choose to have a medically needy eligibility pathway are required
under federal law to cover at a minimum certain children under age 18 and pregnant
women who, except for income and resources, would be eligible as categorically
needy. They are not, however, required to cover the aged, blind, and disabled nor to
cover long-term care services under their medically needy programs, but most do.
As of November 2000, 34 states and the District of Columbia had medically needy
programs.
The medically needy pathway enables many elderly and disabled persons
needing nursing home care to qualify for Medicaid. At an average cost of about
$56,000 per year, nursing home costs can quickly deplete the resources of an elderly
individual, especially after prolonged stays. States, however, are not required to
include nursing facility care among the services covered under their medically needy
programs. As a result, not all states with medically needy programs covering the
elderly provide coverage to persons in nursing homes. Five among the total 34 states
and the District of Columbia that reported having medically needy spend-down
programs did not cover nursing facility services. States not covering nursing facility
care are Arkansas, Florida, Iowa, Oklahoma, and Oregon.
Other Aspects of Spend-Down
States use a specific time period for calculating a person’s medical expenses,
ranging from 1 month to 6 months (as of November 2000).19 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 1 month spend-down calculation period, the individual
would be required to incur $300 in medical expenses in a month, after which services
would be covered by Medicaid. On the other hand, if the state had a 6 month
calculation period, the individual would have to incur a projected amount of $1,800
($300 times 6) 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.
States that do cover nursing facility care under their medically needy programs
have the option of using either the Medicaid or private pay (e.g., private insurance
or out-of-pocket) nursing facility rates as a standard for determining an applicant’s
eligibility. This means that states compare a person’s monthly income to the cost of
nursing home care in that state, either in terms of the total amount that would be paid
by Medicaid for a month (Medicaid rate) or the total amount that would be paid out-
19
Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email,
telephone and fax.
CRS-17
of-pocket (private pay rate). Often the Medicaid monthly rates are lower than the
rates paid by private insurance or out-of-pocket. When the Medicaid rate is lower,
it is harder for applicants to spend-down to the required level, and thus may result in
fewer applicants gaining Medicaid eligibility. (In general, if an applicant’s income
minus the cost of the Medicaid reimbursement or private pay rate, whichever is used
by the state, exceeds the state income limit, then the applicant cannot qualify for
Medicaid coverage of institutional care under a medically needy option.) States’
policies on using either Medicaid or a private pay rate are shown in Table 4 as the
“spend-down basis” for institutional care.
Table 4. Income Limits for Medically Needy (MNIL) and 209(b)
States, and Resources Limits for Aged, Blind, and Disabled
Persons, as of November 2000
State
Protected Protected Protected
monthly
monthly monthly
income
income resources
limit
limit as a
limits
Spend-down
(family of percent of (family of
period
one)
FPL
one)
(months)a
Spend-down
basisb
Alabama
–
–
–
–
–
Alaska
–
–
–
–
–
Arizona
–
–
–
–
–
NF is not a covered
benefit under MN
Arkansas
$108.33
16%
$2,000
3 (noninstitutional
only)
California
$600
86%
$2,000
1
Medicaid
Colorado
–
–
–
–
–
Connecticutj
$476c
68%
$1,600
6
private
Delaware
–
–
–
–
–
District of Columbia
$377
54%
$2,600
6
private
Florida
$180
26%
$5,000
1 (noninstitutional
only)
NF is not a covered
benefit under MN
Georgia
$317
46%
$3,000
1
private
Hawaiij
$418
52%
$2,000
1
Medicaid
Idaho
–
–
–
–
–
Illinoisj
$283
41%
$2,000
1
private
Indianaj
–
–
–
–
–
Iowa
$483
69%
$10,000
2
NF is not a covered
benefit under MN
Kansas
$475
68%
$2,000
1/6
Medicaid
CRS-18
State
Protected Protected Protected
monthly
monthly monthly
income
income resources
limit
limit as a
limits
Spend-down
(family of percent of (family of
period
one)
FPL
one)
(months)a
Spend-down
basisb
Kentucky
$217
31%
$2,000
1/3
private
Louisiana
$100 urban/
$92 rural
14%/
13%
$2,000
1/3
Medicaid
Maine
$315
45%
$3,000
6
private
Maryland
$350
50%
$2,500
6
private
Massachusetts
$522
75%
$650
1/6
Medicaid
Michigani
$408
–
$2,000
1
private
Minnesotaj
$482
69%
$3,000
1/1-6d
Medicaide
Mississippi
–
–
–
–
–
Missourij
–
–
–
–
–
Montana
$508
73%
$2,000
1
Medicaid
Nebraska
$392
56%
$4,000
1
Medicaid
Nevada
–
–
–
–
–
New Hampshirej
$526
76%
$2,500
1-6d
Medicaid
New Jersey
$367
53%
$4,000
1 or 6d /6
private
New Mexico
–
–
–
–
–
New York
$600
86%
$3,600
6f/1
Medicaid
North Carolina
$242
35%
$2,000
6
Medicaid
North Dakotaj
$455
65%
$3,000
1
Medicaid
–
–
–
–
–
$259
37%
$2,000
3 (noninstitutional
only)
NF is not a covered
benefit under MN
NF is not a covered
1 (nonbenefit under MN
institutional
(nor any other longonly)
term care services)
Ohioj
Oklahomaj
Oregon
$413
59%
$2,000
Pennsylvania
$425
61%
$2,400
6
private
Rhode Island
$600
86%
$4,000
1/6
Medicaid
South Carolina
–
–
–
–
–
South Dakota
–
–
–
–
–
CRS-19
State
Protected Protected Protected
monthly
monthly monthly
income
income resources
limit
limit as a
limits
Spend-down
(family of percent of (family of
period
one)
FPL
one)
(months)a
Spend-down
basisb
$241
35%
$2,000
1
Medicaid
Texas
–
–
–
–
–
Utah
$382
55%
$2,000
1
private
Vermont
$708
102%
$2,000
1/6
private
Virginiaj
$250g
36%
$2,000
1/6
Medicaidh
Washington
$539
77%
$2,000
3 or 6d
private
West Virginia
$200
29%
$2,000
1/6
private
Wisconsin
$591.67
85%
$2,000
1/6
private
Wyoming
–
–
–
–
–
Tennessee
Source: Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email, telephone
and fax.
Note: The 2000 federal poverty level (FPL) in the 48 contiguous states and the District of Columbia
was $695.83 per month, ($8,350 per year) for one person. The FPL for Alaska was $869.16 per month
($10,430 per year) for one person. The FPL for Hawaii was $799.16 per month ($9,590 per year) for
one person (Source: HHS Poverty Guidelines, Federal Register, v. 65, no. 31, February 15, 2000.
p. 7555-7557).
a
This column refers to the number of months used to calculate an individual’s pay ability and spenddown. Applicants are divided into two groups, institutional and non-institutional. For those
states in which two numbers are presented (x/y), then x = institutional spend-down period and
y = non-institutional spend-down period. Where one number is presented, it represents the
spend-down period for both groups.
b
This column describes the basis on which institutional spend-down is calculated in medically needy
(MN) programs. States can use either the Medicaid nursing facility (NF) rate or the private pay
rate to calculate an individual’s monthly spend-down requirement. The private pay rate is
higher, therefore resulting in a lower monthly spend-down amount.
c
$476 refers to geographic regions B and C, comprising the majority of Connecticut residents.
Residents living in geographic region A have a protected income amount of $574.
d
Applicants have the option of selecting the spend-down period.
e
The private pay rate is equivalent to the Medicaid reimbursement rate for those nursing facilities that
care for both types of payers.
f
Six months for acute inpatient care.
g
Two regions in Virginia with different protected income levels.
h
The Medicaid payment rate is used only to determine the time during a month in which the recipient
meets his or her spend-down liability. Unlike other states, it is not used to determine a
recipient’s spend-down amount.
i
Spend down levels for Michigan vary by region (Shelter Area). $408 is the spend-down region for
shelter area VI; $391 is for Shelter Area V; $375 is for Shelter Area IV; $350 is for Shelter Area
III; and $341 is for Shelter Area II and I.
j
Income Standard for 209(b) state having a medically needy program.
CRS-20
Incomes up to 100% of FPL
The enactment of Omnibus Budget Reconciliation Act of 1986 (OBRA 86)
offered states another option for covering persons whose income exceeds SSI or
209(b) levels. This option allows states to cover aged and disabled individuals with
incomes up to 100% of the federal poverty level (FPL).20 The American Public
Human Services Association reported that 19 states and the District of Columbia (up
to 100%) used this option as of October 2001. These states were California ( up to
100%), Florida (90%), Georgia (100%), Illinois (85%), Maine (100%),
Massachusetts (100%), Michigan (100%), Minnesota (95%), Mississippi (100%),
Nebraska (100%), New Jersey (100%), North Carolina (100%), Pennsylvania
(100%), Rhode Island (100%), South Carolina (100%), Utah (100%), Vermont
(100%), Virginia (80%). CRS survey data found that Oklahoma (100%) and Hawaii
(100%) also use this option.
Optional Coverage of Institutionalized Persons
Under the 300% Rule
States have another option for covering certain individuals with incomes too
high to qualify for SSI, but 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 nursing home care. To be eligible,
persons must (1) require care provided by a nursing home or other medical institution
for no less than 30 consecutive days, (2) meet the resources standard 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. For 2000,
this limit was $1,536 per month (3 times the monthly SSI payment of $512). In
2002, the limit is $1,635 per month. States may use a level that is lower than the
maximum of 300% of SSI, if they wish. As of November 2000, Delaware, Missouri
and New Hampshire were the only states using income standards that were less than
$1,536.
In November 2000, 34 states used the Special Income Rule to enable persons
to qualify for Medicaid coverage of institutional care. Income eligibility levels for
nursing homes under the Special Income Rule are shown in Table 5.
Fifteen states using the special income rule also have medically needy programs
for making persons eligible for institutional care.21 States that use both pathways are
able to make those persons with incomes below the 300% rule automatically eligible
for coverage, so as to avoid the spend-down computation necessary under medically
20
The poverty guidelines, sometimes referred to as the FPL, are used to determine
eligibility for federal programs. In 2000, the Department of Health and Human Services
(HHS) reported the FPL to be $8,350 for individuals and $11,250 for two people. For more
information see, [http://aspe.hhs.gov/poverty/00poverty.htm]
21
Two states, Missouri and Ohio, have 209(b) spend-down programs and also use the 300%
rule and are included in the total.
CRS-21
needy programs when medical expenses and income must be estimated for a 1 to 6
month time period.22 In November 2000, 18 states used only the special income rule
for making persons eligible for institutional care. These states were Alabama,
Alaska, Arizona, Arkansas, Colorado, Delaware, Florida, Idaho, Iowa, Mississippi,
Nevada, New Mexico, Oklahoma, Oregon, South Carolina, South Dakota, Texas and
Wyoming. However, with a change in law in 1993, these states are now required to
use what can be considered a delayed spend-down process. States must allow
individuals to place income, in excess of the special income level used by states, in
trusts and still be eligible for Medicaid. These trusts are often referred to as “Miller
Trusts”.
Miller Trusts
Prior to an amendment included in the Omnibus Budget Reconciliation Act of
1993 (OBRA 93), persons living in states using only the 300% rule could not qualify
for Medicaid’s coverage of their nursing home care if they had income in excess of
the limit. This meant that persons with as little as $1 more than the limit could not
qualify for Medicaid coverage of their nursing home care, no matter how insufficient
their income and assets might be to cover the cost of their care. As a result of the
OBRA 93 amendment, Medicaid law now requires those states that use only the
special income rule to allow applicants to place income in excess of the special
income level in a special trust, or Miller Trust, and receive Medicaid coverage for
their care.23 Following the individual’s death, the state becomes the beneficiary of
amounts in the trust. This arrangement, which amounts to a delayed spend-down, has
reduced the access barriers for those living in non spend-down states. Table 5 shows
those states that use the special income rule and indicates any limits on income that
might apply in those states using only the 300% rule.
Table 5. Special Income Rule and Miller Trusts for
Institutionalized Individuals, November 2000
Special income
rule
Monthly income
limit as % of SSIa
Miller Income Trust
monthly limit
Alabama
yes
300%
depends on NFb
Alaska
yes
300%
no limit
Arizona
yes
300%
$3,352.91
Arkansas
yes
300%
$2,495
California
no
–
–
Colorado
yes
300%
$3,855
State
22
Persons with incomes above the special income level may qualify as medically needy after
meeting the spend-down requirements.
23
OBRA 1993 codified a 1990 ruling from the United States District Court for the District
of Colorado which first coined the term “Miller Trust.” See Miller v. Ybarra, 746 F.Supp.
79 (E. Colo 1990).
CRS-22
Special income
rule
Monthly income
limit as % of SSIa
Miller Income Trust
monthly limit
Connecticut
no
–
–
Delaware
yes
250%
no limit
District of Columbia
no
–
–
Florida
yes
300%
no limit
Georgia
yes
300%
–
Hawaii
no
–
–
Idaho
yes
300%
no limit
Illinois
no
–
–
Indiana
no
–
–
Iowa
yes
300%
$2,758
Kansas
no
–
–
Kentucky
yes
300%
–
Louisiana
yes
300%
–
Maine
no
–
–
Maryland
no
–
–
Massachusetts
no
–
–
Michigan
yes
300%
–
Minnesota
yes
300%
–
Mississippi
yes
300%
no limit
Missouri
yes
175%c
–
Montana
no
–
–
Nebraska
no
–
–
Nevada
yes
300%
no limit
New Hampshire
yes
244%
–
New Jersey
yes
300%
–
New Mexico
yes
300%
no limit
New York
no
–
–
North Carolina
no
–
–
North Dakota
no
–
–
Ohio
yes
300%
–
Oklahoma
yes
300%
$2,500
State
CRS-23
State
Special income
rule
Monthly income
limit as % of SSIa
Miller Income Trust
monthly limit
Oregon
yes
300%
no limit
Pennsylvania
yes
300%
–
Rhode Island
yes
300%
–
South Carolina
yes
300%
no limit
South Dakota
yes
300%
no limit
Tennessee
yes
300%
–
Texas
yes
300%
no limit
Utah
no
–
–
Vermont
yes
300%
–
Virginia
yes
300%
–
Washington
yes
300%
–
West Virginia
yes
300%
–
Wisconsin
yes
300%
–
Wyoming
yes
300%
no limit
Source: Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email, telephone
and fax.
a
The special income rule refers to 300% of the federal benefit payment, or 3 times $512 in 2000.
States that apply the special income rule at the 300% level, therefore, protect $1,536 of income
per month.
b
If an applicant’s income exceeds $3,000 after the liability amount is given to the nursing home, he
or she would be deemed ineligible for nursing facility coverage under Medicaid.
c
Missouri adjusts its monthly income limit by the cost-of-living adjustment (COLA).
Optional Coverage for Persons Needing Home and
Community-Based Long-Term Care
States have the option of covering persons needing home and community-based
long-term care services, if these persons would otherwise require institutional care
that would be paid for by Medicaid. Section 1915(c) of the Medicaid statute allows
the Center for Medicare and Medicaid Services (CMS) to waive certain federal
requirements in order to allow states to cover a wide range of home and communitybased services (HCBS). Services that states may choose to cover 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 CMS as cost
effective and necessary to avoid institutionalization.
CRS-24
As of 2000, 49 states and the District of Columbia provided at least one or more
of these services through 1915(c) waivers. Arizona provides similar services through
the Section 1115 demonstration waiver program.
Under the law, states can request authority to waive certain statutory
requirements that would otherwise apply to services covered under a state’s Medicaid
program. Three Medicaid requirements may be waived:
!
Waiver of statewideness. Medicaid law requires Medicaid covered
services to be available on a statewide basis (Section 1902(a)(1)).
Section 1915(c) allows states, instead, to cover services in only a
portion of the state, rather than in all geographic jurisdictions.
!
Waiver of comparability requirements. Medicaid law requires that
Medicaid covered services be available in the same amount,
duration, and scope to all individuals eligible under a state’s plan
(Section 1902(a)(10(B)). Section 1915(c) allows states to cover
home and community-based services for specific groups, for
example, the elderly, or persons with disabilities, rather than for all
eligible Medicaid beneficiaries. Waiver of this requirement allows
states to limit the number of recipients who may be eligible for
services and to provide services to some groups, but not others.
!
Waiver of financial eligibility requirements. Medicaid law requires
that states use a single standard to determine income and resources
when determining an applicant’s eligibility for Medicaid. Section
1915(c) allows states to use more liberal income eligibility
requirements for persons needing home and community-based longterm care waiver services, such as the 300% rule.
Eligibility Requirements
In order to be eligible for home and community-based long-term care waiver
services, a person 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, and persons with
mental illness. States must apply for separate waivers to serve each of these different
groups. States may define categories of individuals who may be eligible for certain
waivers and the services they should receive. For example, they may cover only the
elderly for case management services, or only the disabled for personal attendant
services. States may also limit services to individuals who have certain conditions
(such as AIDS) or illnesses (such as the chronically mentally ill). Although states
may amend the waivers to serve additional recipients, states may also set overall
limits on the total number of persons to be served under a waiver. This ability to
define and limit eligibility allows states to control costs for the program.
Recipients of 1915(c) waiver services must meet both financial and functional
(described below) eligibility requirements set by state and federal law. Under
1915(c) waivers, states may limit coverage to those persons receiving SSI and or SSP
(209(b) states may limit coverage to persons meeting more restrictive standards) or
CRS-25
allow persons to qualify under their medically needy standards (described above).
States also have the option of setting financial eligibility limits for income as high as
300% of SSI benefits, generally the same level states use for nursing facilities. Those
states that use the 300% rule may also allow eligibles to establish Miller trusts if
those states do not also have medically needy programs. All states, except Indiana,
use higher income levels than the SSI level. Indiana used the SSI income standard
but applies more restrictive standards for counting income and resources as well as
for defining disability than under federal SSI law.
States also have the option of applying spousal impoverishment protections
(discussed below) for couples when only one of the spouses requires Medicaid
coverage of long-term care expenses. As of April 2000, 46 states applied the same
asset standards to their waiver programs as they used for nursing homes. In Table
6, the eligibility pathways selected by states for HCBS waiver programs are shown.
The last three columns pertaining to minimum maintenance needs allowance and
spousal impoverishment are described later in this report.
Table 6. Pathways and Protected Income and Resources Levels
Used to Determine HCBS Waiver Program Eligibility, November
2000
Spousal
impoverishMNA
MNA as a ment rules
applye
(Individual)c % of FPLd
State
Eligibility
pathwaysa
Groups
coveredb
Alabama
300% rule
ABD
$1,536
221%
no
Alaska
300% rule,
Miller Trusts
AD
$1,536
221%
yes
Arizona
300% rule,
Miller Trusts
ABD
$204
29%
yes
Arkansas
300%
ABD
$1,536
221%
no
California
MN
ABD
$600
86%
yes
Colorado
300% rule,
Miller Trusts
ABD
$1,536
221%
yes
Connecticut
300% rule
ABD
$1,392
200%
yes
Delaware
300%, Miller
Trusts
ABD
$1,280
184%
yes
District of Columbia
300% rule, MN
A (SSI only
for D)
$1,536
221%
yes
Florida
300% rule,
Miller Trusts
ABD
depends on
waiver
Georgia
Cap at $1,590
ABD
$530
no
76%
yes
CRS-26
State
Eligibility
pathwaysa
Groups
coveredb
Spousal
impoverishMNA
MNA as a ment rules
applye
(Individual)c % of FPLd
equivalent to
income
ceiling of
54% (MN
qualifying plus $20) or
eligibility 103% (FPL
pathway plus at 100%
$20
plus $20)
Hawaii
MN, FPL at
100%
AD (B
based on
MN, SSI
only)
Idaho
300% rule,
Miller Trusts
ABD
$796
114%
yes
Illinois
MN, FPL at 70%
ABD
$487
70%
yes
74%
no
yes
Indiana
209(b) rules
ABD
$512 for
children
under 18 or
students 1821 only
Iowa
300% rule
ABD
$1,536
221%
yes
Kansas
FPL at 100%
ABD
$687
99%
yes
Kentucky
300% rule, MN
ABD
$532
76%
yes
Louisiana
300% rule
ABD
$1,536
221%
yes
Maine
300% rule, MN,
FPL at 100%
ABD
$870
125%
no
Maryland
300% rule, MN
BD (MN for
A only)
$480
69%
yes
Massachusetts
MN, FPL at
100%
ABD
$522
75%
no
Michigan
300% rule
ABD
$1,536
221%
yes
Minnesota
ABD
(300% rule
used for A
300% rule, MN
only)
Mississippi
300% rule,
Miller Trusts
ABD
$1,536
221%
yes
Missouri
300% rulef
ABD
$896
129%
yes
Montana
MN
ABD
$508
73%
no
Nebraska
MN
ABD
$392
56%
yes
Nevada
300% rule,
Miller Trusts
ABD
$1,024g
147%
yes
MN
ABD
depends on
waiver
–
no
New Hampshire
$700 for A, 101% for A, yes (for
$487 for D 70% for D elderly only)
CRS-27
Spousal
impoverishMNA
MNA as a ment rules
applye
(Individual)c % of FPLd
Eligibility
pathwaysa
Groups
coveredb
New Jersey
300% rule, FPL
at 100%
ABD
$1,536
221%
yes
New Mexico
300% rule,
Miller Trusts
ABD
$1,516
218%
yes
New York
MN
ABD
$600
86%
yes
North Carolina
MN, FPL at
100%
ABD
$696
100%
yesh
North Dakota
MN
ABD
$455
65%
yes
Ohio
300% rule
ABD
$1,001
144%
yes
Oklahoma
300% rule,
Miller Trusts
ABD
$1,536
221%
yes
Oregon
300% rule,
Miller Trusts
ABD
$513.70
74%
yes
Pennsylvania
300% rule
ABD
$1,536
221%
no
Rhode Island
300% rule, MN
AD
$600
86%
noi
South Carolina
300% rule,
Miller Trusts
ABD
$512
74%
yes
South Dakota
300% rule
ABD
$530
76%
yes
Tennessee
300% rule, MN
ABD
$1,024
147%
no
Texas
300% rule,
Miller Trusts
ABD
$1,536
221%
yes
Utah
300% rule, MN,
FPL 100%
ABDj
$696
100%
yes
MN
ABD
$766
110%
yes
State
Vermont
74%
$512 ($1,536 (221% for
for AIDS
AIDS
waiver)
waiver)
300% rule, MN
ABDk
Washington
300% rule
ABD
$696ll
100%
yes
West Virginia
300% rule
ABD
$1,536
221%
yes
Wisconsin
300% rule, MN
ABD
$616
89%
yes
Wyoming
300% rule,
Miller Trusts
ABD
$1,536
221%
yes
Virginia
yes
Source: Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email, telephone
and fax.
CRS-28
a
This column indicates the highest income eligibility pathways in which a person can become eligible
to receive Medicaid HCBS services. The choices provided to state respondents included SSI
(income and resources of the Supplemental Security Income program), 300% rule (income
standard of 300% of SSI and SSI resources standards) and availability of Miller Trusts, MN
(income and resources standards of the states’ Medically Needy program), FPL (a specified
percentage of the Federal Poverty Level), and 209(b) (income, resources and/or disability
standards more restrictive than SSI).
b
This column describes those groups of individuals for whom waiver services are available. For the
purpose of this report, survey choices included aged, blind and/or disabled. Although the
information was not requested in this survey, some states provide HCBS waiver services to only
a subgroup of the above listed categories, such as only those individuals with mental retardation
or developmental disabilities, or only those individuals with AIDS.
c
This is the amount of money an individual is allowed to keep to use to pay for community living
expenses, such as housing, transportation, food, etc., while enrolled in a HCBS waiver program.
d
This column shows the amount of monthly protected income for an individual receiving HCBS
waiver services as a percentage of the federal poverty level (FPL). The 2000 federal poverty
level (FPL) in the 48 contiguous states and the District of Columbia was $695.83 per month,
($8,350 per year) for one person. The FPL for Alaska was $869.16 per month ($10,430 per
year) for one person. The FPL for Hawaii was $799.16 per month ($9,590 per year) for one
person (Source: HHS Poverty Guidelines, Federal Register, v. 65, no. 31, February 15, 2000.
p. 7555-7557).
e
When used, these rules typically apply in situations where both members of couples live in the home
but only one member is enrolled in the waiver program.
f
The special income rule is 175% of SSI. Waivers apply only to individuals age 65 and older and to
individuals with Mental Retardation and Developmental Disabilities (MRDD) under age 18.
g
Two hundred percent of the federal benefit rate (FBR) for aged, and 300% of FBR for all other
individuals in waiver programs.
h
Spousal impoverishment rules apply only to resources as states do not perform post-eligibility
assessments on spouses of waiver participants.
i
Spousal impoverishment rules apply only to assisted living waiver programs.
j
MN and 300% rule apply only to waivers for individuals with physical disabilities.
k
MN does not apply to waiver services for individuals with mental retardation and developmental
disabilities.
l
Married individuals whose spouses are not receiving HCBS and individuals living in alternative
living facilities have $539 protected. This is the medically needy income standard. Individuals
participating in the AIDS waiver and living at home may maintain up to $1,536 of protected
income.
Level of Care Eligibility Criteria for Institutional and
Community-Based Long-Term Care Services
Not only must persons meet Medicaid’s financial and categorical eligibility
criteria in order to receive institutional and home and community-based long-term
care services, but they must also meet certain level of care criteria. Federal statute
restricts institutional and HCBS waiver services to persons who would require a level
of care provided in a nursing facility, hospital or intermediate care facility for the
mentally retarded. The diversity of conditions that creates a need for long term care
makes designing measures to adequately and uniformly assess applicants’ physical,
cognitive and mental conditions difficult.
The measures used by states to determine an applicant’s eligibility for long-term
care services vary. A survey of 42 states conducted by the American Association of
Retired Persons (AARP) in 1996 found the following three types of measures to be
those most commonly used: 1) states that score specific factors and require a
minimum score for eligibility, 2) states that require a minimum number of specific
CRS-29
impairments or needs for eligibility, and 3) states that use level of care definitions
and guidelines to determine eligibility. This study found that those states requiring
a minimum score and those states that counted number of impairments considered
medical and nursing needs, mental and physical impairments, activities of daily
living (ADLs) and instrumental activities of daily living (IADLs) when determining
an applicants’ eligibility.24 The survey also found that those states using criteria
based on definitions and guidelines to determine eligibility provided the assessor
with a greater amount of discretion than those applying the other two assessments.
In general, rather than requiring an assessor to determine whether an applicant has
three out of five ADL impairments, an assessor in a state using the third approach
may be required to determine whether an applicant meets one of a number of general
criteria, including a “need for nursing services.”25
Other Mandatory and Optional Coverage Pathways
Federal law requires states to cover additional groups of elderly and disabled
persons. These groups include those discussed below.
Persons Eligible for Medicare Cost-Sharing Assistance
Certain low-income elderly and disabled individuals who are eligible for
Medicare may also be eligible to have some of their Medicare cost-sharing expenses
paid for by Medicaid.
Qualified Medicare Beneficiary (QMB). Qualified Medicare Beneficiaries
are aged or disabled individuals with incomes at or below the federal poverty level.
This means that to be eligible for the QMB benefits under Medicaid, a Medicare
beneficiary’s income must be no greater than 100% of the federal poverty level.
Applicants’ assets may not exceed $4,000 for an individual and $6,000 for a couple.
Under QMB, Medicaid covers the costs of Medicare premiums, deductibles, and
coinsurance for Medicare covered benefits.
24
ADLs refer to activities necessary to carry out basic human functions, and include the
following: bathing, dressing, eating, getting around inside the home, toileting, and
transferring from a bed to a chair. IADLs refer to tasks necessary for independent
community living, and include the following: shopping, light housework, telephoning,
money management, and meal preparation.
25
For example, Arkansas’ 1996 guidelines acknowledged the potential for the functional
eligibility test to be applied inconsistently. It states that they “cannot be used in a checklist
fashion or as a rigid criteria for approving or denying access to nursing home care.” Rather
they are “to be used as a general framework for the exercise of professional judgment.
Other factors to be considered are the applicant’s age, diagnosis, mental status, and overall
condition.” O’Keeffe, Dr. P.H., R.N., Janet. Determining the Need for Long-Term Care
Services: An Analysis of Health and Functional Eligibility Criteria in Medicaid Home and
Community Based Waiver Programs. #9617, Public Policy Institute, AARP, Washington,
D.C., December 1996.
CRS-30
Specified, Low-income Medicare Beneficiary (SLMB). SLMB benefits
are available to Medicare recipients whose income is no greater than 120% of FPL.
The asset test is the same as that for QMB. Under this Medicaid pathway, benefits
include only the monthly Medicare Part B premium. Medicare Part B provides
coverage for physicians’ services, laboratory services, durable medical equipment,
hospital outpatient department services, and other medical services.
Medicaid coverage for QMBs and SLMBs is limited to Medicare cost-sharing
charges. Other Medicaid covered services, such as nursing facility care, prescription
drugs and primary and acute care services, are not covered for these individuals
unless they qualify through other eligibility pathways into Medicaid (e.g. via SSI,
medically needy or special income rule).
Qualifying Individuals (QI-1 and QI-2). If a Medicare recipient’s income
is between 120 and 135% of poverty, the QI-1 option may pay the monthly Medicare
Part B premium for these individuals. If a Medicare recipient’s income exceeds the
QI-1 criteria but does not exceed 175% of poverty, he or she may qualify for costsharing assistance through the QI-2 option. Under QI-2, state Medicaid programs pay
that portion of the monthly Part B premium attributable to the gradual transfer of
some home health visits from Medicare Part A to Medicare Part B.26
Qualified Disabled and Working Individuals (QDWIs). Medicaid is
authorized to provide partial protection against Medicare Part A premiums for
Qualified Disabled and Working Individuals. QDWIs are persons who were
previously entitled to Medicare on the basis of a disability, who lost their entitlement
based on earnings from work, but who continue to have a disabling condition.
Medicaid is required to pay the Medicare Part A premium for such persons if their
incomes are below 200% of the federal poverty line, their resources are below 200%
of the SSI limit ($4,000), and they are not otherwise eligible for Medicaid. States are
permitted to require individuals whose income is between 150% and 200% of
poverty to pay a portion of the premium, based on a sliding scale. QDWIs are further
discussed below.
26
In general, Medicaid payments are shared between the federal government and the states
according to a matching formula. However, expenditures under the QI-1 and QI-2 programs
are paid for 100% by the federal government (from the Part B trust fund) up to the state’s
allocation level. A state is only required to cover the number of persons which would bring
its spending on these population groups in a year up to its allocation level. Total allocations
are $200 million in FY1998, $250 million for FY1999, $300 million for FY2000, and, $350
million for FY2001, and $450 million for FY2002. Assistance under the QI-1 and QI-2
programs is available for the period January 1, 1998 to December 31, 2002.
CRS-31
Other Pathways
Under the Pickle Amendment (P.L. 94-566, Section 503), a state must cover
former SSI recipients who; 1) are receiving Social Security benefits (OASDI), 2)
formerly qualified for Medicaid because of simultaneous eligibility for SSI or SSP,
and 3) would be eligible for SSI or SSP but for the cost-of-living adjustment (COLA)
in Social Security benefits after April 1977.27 In addition, COLAs paid to the
individual’s spouse or parent cannot be deemed available to the individual. In 209(b)
states, Medicaid must be provided to these persons when their income, after disregard
of the COLA and spend-down of incurred medical expenses, falls below the state
standard.
Special Rules for Children with Disabilities
Children with disabilities can become eligible for Medicaid through each of the
welfare-related and medically needy pathways described above. In addition, there are
other eligibility rules that apply only to children with disabilities. These are
described below.
For a child under the age of 20 and living at home, the income and resources of
the child’s parents are automatically considered available for medical care expenses;
that is, they are “deemed” to the child. If the same child is institutionalized, however,
after the first month away from home, the child is no longer considered to be a
member of the parents’ household and only the child’s own financial resources are
considered available for care.
This policy had resulted in some children remaining in institutions even while
their medical needs could be met at home. This situation was dramatized in 1982 by
the case of Katie Beckett, a child who was dependent on a ventilator and was unable
to go home, not because of medical reasons but because she would no longer have
been eligible for Medicaid and her family was unable to afford alternative health
coverage.
To address this issue, Congress amended Medicaid to include a provision,
sometimes referred to as the Katie Beckett provision, that allows states to extend
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 intermediate
care facility for individuals with mental retardation. 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, on a statewide
basis, all disabled children who meet these criteria. As of May 2000, 20 states
covered this group of disabled children under Medicaid. These states are Alaska,
Arkansas, Delaware, Georgia, Idaho, Maine, Massachusetts, Michigan, Minnesota,
Mississippi, Nebraska, Nevada, New Hampshire, Rhode Island, South Carolina,
South Dakota, Virginia, Vermont, West Virginia and Wisconsin.
27
Pertains to all cost-of-living increases made after April 1977.
CRS-32
Children with special needs might also qualify for home and community-based
long-term care services if the state in which they live has chosen to implement a
1915(c) waiver program for children with disabilities. To qualify, children would
need to otherwise require institutional care. Such programs have capped enrollment
and are often limited to a defined geographical location (a county). See above for
more information on 1915(c) programs.
Disabled children who are not able to become eligible for Medicaid under these
special rules could, of course, become eligible through the program’s traditional
pathways that are not specific to individuals with disabilities. Disabled children can
become eligible for Medicaid through poverty-related pathways, AFDC-related
pathways, as well as through medically needy programs.28
Rules Applying to Disabled Individuals
Engaged in Work
Because many disabled workers may not have access to affordable or adequate
health insurance through their jobs, the risk of losing Medicaid coverage due to
employment earnings can be a disincentive to work.29 Prior to 1980, a disabled SSI
recipient who worked faced substantial risk of losing both SSI cash benefits and
Medicaid. In response to this and other work disincentives, Congress created a
variety of special rules for the purpose of protecting working individuals with
disabilities from losing their SSI and Medicaid benefits.
In order to qualify for SSI and, thus become eligible for Medicaid, applicants
must establish disability status under the criteria determined by the Secretary of the
Department of Health and Human Services (DHHS). These criteria are linked to an
individual’s ability to work or earn income from work, commonly referred to as an
individual’s ability to “engage in substantial gainful activity” (SGA). Current
regulations provide that an individual is able to engage in SGA if his or her earnings
exceed $780 a month for non-blind disabled and $1,300 for blind in 2002, with
impairment-related expenses subtracted from earnings.30 If persons applying for SSI
have demonstrated the ability to engage in SGA, they will not be able to establish
disability status. (See section entitled Welfare-Related Pathways of this report for
more information.)
28
Furthermore, children have access to Medicaid through the State Children’s Health
Insurance Program (SCHIP). For more information on eligibility groups, see CRS Report
RL30632, Reaching Uninsured Children: are Medicaid and SCHIP Doing the Job?, by
Trish Riley and Elicia Herz.
29
Medicaid offers individuals coverage of certain benefits, such as mental health care
medications and personal attendant services that are not often available through private
health insurance.
30
Generally, to qualify for SSI, the individual must be unable to do any kind of work that
exists in the national economy, taking into account age, education and work experience.
CRS-33
For those who are already covered by SSI, however, a different set of rules
applies. Section 1619(a) of SSI law, for example, provides for the continuation of
special SSI cash benefits for those persons receiving SSI on the basis of disability
even if they are working at the SGA level, as long as there is not a medical
improvement in the disabling condition. The amount of their special cash benefits
is gradually reduced as their earnings increase under an income disregard formula
until their countable earnings reach the SSI benefit standard or what is known as the
breakeven point. In a state with no state supplemental payment, this earned income
eligibility limit is $1,175 per month in 2002 for a person who has no unearned
income (e.g., Veterans pension, OASDI payments, etc.). For states that supplement
the federal SSI benefit standard, the breakeven point increases $2 for every $1 of
state supplementation above the federal benefit standard.
Blind and disabled individuals can continue to be eligible for Medicaid even if
their earnings take them past the SSI income disregard breakeven point. Special
eligibility status granted by Section 1619(b)(1), under which the individual is
considered an SSI recipient for purposes of Medicaid eligibility (although he or she
is not actually receiving SSI) applies as long as the individual: (1) continues to be
blind or have a disabling impairment; (2) continues to meet all the other
requirements, except for earnings, for SSI eligibility; (3) would be seriously inhibited
from continuing to work by the termination of eligibility for Medicaid services; and
(4) has earnings that are not sufficient to provide a reasonable equivalent to the
benefits that would have been available if he or she did not have those earnings from
SSI, state supplementary payments, Medicaid and publicly funded personal care.31
To further reduce work disincentives and improve opportunities for individuals
with disabilities who rely on Medicaid for their health care needs to participate in the
labor force, Congress enacted legislation in 1997 and 1999. This legislation
expanded state flexibility in creating Medicaid “buy in” opportunities for individuals
with disabilities. The first piece of legislation was added by the Balanced Budget Act
of 1997 (BBA97). BBA97 allows states to elect to provide Medicaid coverage to
disabled working individuals whose family income does not exceed 250% of the
FPL. The second piece of legislation was added by Ticket to Work and Work
Incentives Improvement Act of 1999 (P.L. 106-170, TWWIIA). TWWIIA allows
states to further expand Medicaid coverage to the working disabled, between the ages
of 16 and 64, with incomes above 250% of the FPL. In addition, assets may not
exceed standard SSI limits. Under both of these provisions, disabled persons who
are working may have to purchase or “buy into” Medicaid coverage through the
payment of premiums and/or co-payments. These options were designed to expand
the number of disabled individuals who could continue working while maintaining
their Medicaid coverage.
As of April 1, 2002, 27 states had enacted legislation for a Medicaid buy-in
program. Of these, 19 states had implemented buy-in program (16 states have over
1 year of implementation experience). The remaining eight states were in the policy
31
A similar provision to 1619(b) exists under Medicaid law in Section 1905(q). The
provision refers to this group of individuals as Qualified Severely Impaired Blind or
Disabled Individuals under age 65.
CRS-34
refinement and pre-implementation phase. Several other states have introduced
Medicaid buy-in bills to their respective state legislatures.32
Rules Applying to Individuals who are Homeless
Elderly and disabled individuals who are homeless may also be eligible for
Medicaid. In order to qualify, an individual must still meet the program’s financial
and categorical eligibility criteria. However, a state may not exclude from coverage
any eligible person who resides in the state, regardless of whether the residence is
maintained at a fixed address. States are required to provide a method of making
eligibility cards available to eligible individuals who do not reside in a permanent
dwelling or do not have a permanent home or mailing address.
Rules Applying to the Transfer of Assets
Some years prior to the passage of Omnibus Budget Reconciliation Act of 1993
(OBRA 93), Congress began to be concerned with a practice commonly referred to
as Medicaid estate planning. Medicaid estate planning is a means by which elderly
people shelter their income and assets in order to qualify for Medicaid’s coverage of
long-term care services sooner than they would if they had spent their income on the
cost of care. Such practices included (1) converting “countable assets into “exempt
assets,” (2) sheltering assets in trusts, annuities, and other financial instruments that
are deemed “not available” to the Medicaid applicant to pay for nursing home care,
or (3) transferring assets through joint bank accounts. The goal of this practice was
to protect resources for the individual and/or heirs, while appearing to be “poor
enough” to qualify for Medicaid.
To try to ensure that Medicaid applicants apply their assets to the cost of their
care and do not give them away in order to gain Medicaid eligibility sooner than they
otherwise would, OBRA 93 established penalties under Medicaid for the transfer of
assets for less than fair market value. Specifically, Medicaid has required that states
delay Medicaid eligibility for institutionalized individuals and for certain services
(including home and community-based services provided under waivers) provided
to non-institutionalized persons who dispose of assets for less than fair market value
on or after a “look-back date.” This date is 36 months prior to application for
Medicaid or 60 months if the transfer is made through an irrevocable trust. In other
words, transfers are prohibited during the 3-year or 5-year period prior to application
for Medicaid. The law also prohibits spouses of these persons from transferring
assets during this same period. If the state has determined that a transfer occurred,
then applicants may be subject to delay in eligibility. Certain transfers are permitted
to spouses, to minor or disabled children, or to trusts solely for the benefit of disabled
persons under 65.
32
See CRS Report RL31157, Ticket to Work and Work Incentives Improvement Act of 1999:
Implementation Status, by Jennifer Hess.
CRS-35
The length of the period of ineligibility for institutionalized and noninstitutionalized individuals is determined by dividing the total cumulative
uncompensated value of all assets transferred on or after the look-back date by the
average monthly cost to a private patient of a nursing facility in the state (or, at the
option of the state, in the community in which the individual is institutionalized) at
the time of application. For example, a transferred asset worth $60,000, divided by
a $5,000 average monthly private-pay rate, results in a 12-month penalty period.
There is no limit to the length of the penalty period. This period of ineligibility
begins with the first month during which the assets were transferred.
Medicaid Estate Recovery
Congress also included other provisions in OBRA 93 to address concerns with
estate planning. Since OBRA 93, Medicaid statute has mandated all 50 states and the
District of Columbia to recover from the individual’s estate amounts paid for nursing
facility services, home and community-based services and related hospital and
prescription drug services. In addition, states are given the option of recovering
funds spent on additional items or services covered under the state’s Medicaid plan.
Adjustment or recovery may only be made after the death of the individual and his
or her surviving spouse, if any, and only at a time when there is no surviving child
under age 21 or a child who is blind or permanently and totally disabled.33
For purposes of these recovery provisions, estates are defined to include all real
and personal property and other assets included within an individual’s estate, as
defined under state laws governing the treatment of inheritance. At the option of the
state, recoverable assets also include any other real and personal property and other
assets in which the individual had any legal title or interest at the time of death,
including such assets conveyed to a survivor, heir, or assign of the deceased
individual through joint tenancy, tenancy in common, survivorship, life estate, living
trust, or other arrangement. These provisions apply for persons who received such
medical assistance at 55 years of age or older.34 Medicaid law and regulations also
require states to establish procedures for waiving the application of these rules in
cases of undue hardship.
Special provisions apply to persons who become eligible for Medicaid under a
more liberal asset standard used in certain states for those who purchase long-term
care insurance. The statute prohibits states from recovering from the estates of
individuals who received medical assistance under a state plan amendment, approved
by May 14, 1993, which provided for disregarding any assets or resources related to
payments made under a long-term care insurance policy or because an individual has
received (or is entitled to receive) benefits under a long-term care insurance policy.
33
In addition, states can not recover against a beneficiary’s home on which the state has
placed a lien, unless additional protections for siblings and adult children are satisfied.
34
There is no document that records or explains why the age floor was changed from 65
years old (in pre-OBRA 93 statute) to 55 years old (by OBRA 93).
CRS-36
States with such amendments are California, Connecticut, Indiana, Iowa (few
individuals have participated in the Iowa program as of April 2002) and New York.35
Finally, among the Medicaid Estate Recovery provisions in OBRA 1993 is a
provision requiring the state agency to establish procedures for waiving the
application of adjustment or recovery if it would cause an undue hardship (as
determined on the basis of criteria established by the Secretary).
Rules Applying to Institutionalized Persons with
Spouses Living at Home
Medicaid law includes provisions to prevent spousal impoverishment – a
situation that leaves the spouse who lives at home in the community with little or no
income or resources when the other spouse requires institutional or home and
community-based long-term care.36 These provisions were added to Medicaid law
by the Medicare Catastrophic Coverage Act (MCCA) of 1988. Before MMCA, states
could consider all of the assets of the community spouse, as well as the
institutionalized spouse, available to pay for the cost of medical care for an
institutionalized spouse under Medicaid. These rules created hardships for the
spouse living in the community who was forced to spend-down virtually all of the
couple’s assets to Medicaid eligibility levels so that the institutionalized spouse could
qualify for Medicaid. MCCA established new rules for the treatment of income and
resources of married couples to determine how much income or resources a
community spouse must contribute toward the cost of care for the spouse requiring
the care, and how much of the institutionalized spouse’s income and resources is
actually protected for use by the community spouse.
For example, today the income of many elderly couples comes largely from the
Social Security and pension benefits that the husband receives because of his work
history in the labor force. The wife, who may have had limited or no attachment to
the work force, may receive only a small Social Security benefit in her own name.
If the husband requires nursing home care and seeks Medicaid coverage for his care
under a state’s medically needy program, for instance, most states, prior to spousal
impoverishment protections, considered the husband’s income his for purposes of
determining eligibility. They also considered resources held in the husband’s name,
35
Other states that did not file a state plan amendment prior to May 14, 1993, such as
Illinois and Washington, also allow persons who purchased long-term care insurance
policies to protect a certain amount of assets. The OBRA 93 provision allowed California,
Connecticut, Indiana, Iowa and New York to waive recovery of a person’s resources related
to payments under a private long-term care insurance policy. Although Illinois and
Washington are required to recover any assets or resources initially disregarded because of
the payments made by a qualified long-term care insurance policy, they allow individuals
to transfer these assets up until the time of their death even while they are receiving
Medicaid covered services.
36
Report of the Special Committee on Aging United States. Developments in Aging: 1997
and 1998 Volume 1. Pursuant to S. Res. 54, Sec. 19(c), February 13, 1997, 106th Congress,
2nd Session. Senate Report 106-229, February 7, 2000.
CRS-37
as well as jointly held resources, to be fully available to him and would require that
these resources be spent down to the states resource standard before considering him
Medicaid eligible. In most states, this could mean that the community spouse would
have been left with only $2,000 in assets held, for example, in a savings account.
Following eligibility, Medicaid’s post-eligibility rules considered the husband’s
income to be available for the cost of his care, and allowed a deduction to be made
for his wife’s living expenses only to the extent that her own income did not exceed
the standard specified by the state. In most states, this standard was the basic SSI
benefit level, or less. This meant that a wife with little or no income of her own
would have available for her living expenses an amount less than the federal poverty
level.
Protected Resources. Spousal impoverishment resource eligibility rules
provide for a method of counting a couple’s resources in initial eligibility
determinations. Under the rules, states must assess a couple’s combined countable
resources, when requested by either a spouse, at the beginning of a continuous period
of institutionalization (defined as at least 30 consecutive days of care). The Centers
for Medicare and Medicaid Services’ (CMS) guidance on implementing spousal
impoverishment law requires that nursing homes advise people entering nursing
homes and their families that resource assessments are available upon request. The
couple’s home, household goods, and personal effects are excluded from countable
resources. In addition, 209(b) states may not use more restrictive policies for
defining these resources under spousal impoverishment law.
MCCA allows states to protect resources equivalent to the amount of a
community spouse resources allowance (CSRA).37 Federal restrictions limit the
maximum amount states can allow community spouses’ to retain. This is the greater
of an amount equal to one-half of the couple’s resources at the time the
institutionalized spouse entered the nursing home, up to a maximum of $84,120 as
of 2000 ($89,280 in 2002), or the state standard. Federal law stipulates that state
standards may be no lower than $16,824 in 2000 ($17,856 in 2002). Maximum and
minimum CSRA amounts are adjusted annually at the federal level by the same
percentage as the consumer price index (CPI).38 When the community spouse’s half
of the couple’s combined resources is less than the state standard, the
institutionalized spouse may transfer resources to the community spouse to bring that
spouse up to the state standard. If, on the other hand, the community spouse’s
resources exceed the CSRA, he or she may be required to apply the excess resources
to the nursing home spouse’s cost of care. Section 209(b) states may not use more
37
These resource eligibility determinations are performed at the request of either spouse and
can be associated with a fee when not conducted in conjunction with an application for
Medicaid eligibility. HCFA guidance on implementing spousal impoverishment law
requires that nursing homes advise people entering nursing homes and their families that
resources assessments are available upon request.
38
Ahmad, Omar N. Medicaid Eligibility Rules for the Elderly Long-Term Care Applicant.
History and Developments, 1965-1998. The Journal of Legal Medicine, Taylor and Francis.
June 1999.
CRS-38
restrictive policies for defining these resources under spousal impoverishment law.
Table 7 shows state spousal resources standards as of November 2000.
Protected Income. The spousal impoverishment protections do not permit
income of community spouses to be used in determining the nursing home spouse’s
eligibility unless the income is actually made available to the institutionalized spouse.
Thus, all of the community spouse’s income is protected for use by the community
spouse and need not be applied to the cost of institutional care. MCCA also required
states to establish an income level that the community spouse can retain without
affecting the institutionalized spouse’s eligibility for Medicaid. The rules require that
states recognize a minimum maintenance needs allowance (MMNA) for the living
expenses of the community spouse. This minimum according to federal law can be
no lower than 150% of the federal poverty level. As of 2000, the minimum was
$1,406.25 per month. States can set the maintenance needs allowance as high as
$2,103 per month in 2000. States can increase this amount, depending on the amount
of the community spouse’s actual shelter costs and whether the minor or dependent
adult children or certain other persons are living with the community spouse. Both
of these minimum and maximum amounts are adjusted at the federal level to reflect
increases in the CPI.
To the extent that income of the community spouse falls below the state’s
maintenance need standard and the institutionalized spouse wishes to make part of
his or her income available to the community spouse, the nursing home spouse may
supplement the income of the community spouse to bring the spouse up to the state
standard. Table 7 shows state spousal income standards for November 2000.
Table 7. Spousal Impoverishment: State Protected Income and
Resources Amounts, November 2000
Community spouse’s minimum
maintenance needs allowance
(monthly protected income)a
State
Income
% of poverty
Community spouse’s
protected resources
amountsb
Alabama
$1,407
202%
$84,120
Alaska
$2,103
302%
$84,120
Arizona
$2,103
302%
$84,12
Arkansas
$1,406.25
202%
$16,824
California
$2,1030
302%
$84,120
Colorado
$1,407
202%
$84,120
Connecticut
$1,406-$2,103
202%-302%
$16,824-$84,120
Delaware
$1,407-$2,103
202%-302%
$25,000-$84,120
District of Columbia
$2,103
302%
$16,824
Florida
$2,103
302%
$84,120
CRS-39
Community spouse’s minimum
maintenance needs allowance
(monthly protected income)a
State
Income
% of poverty
Community spouse’s
protected resources
amountsb
Georgia
$2,103
302%
$84,120
Hawaii
$2,103
302%
$84,120
Idaho
$1,407
202%
$16,900-$84,120
Illinois
$2,103
302%
$84,120
Indiana
$1,407-$2,103
202%-302%
$16,824-$84,120
$2,103
302%
$24,000-$84,120
$1,407-$2,103
202%-302%
$16,824-$84,120
Kentucky
$2,103
302%
$84,120 (nonexcludable)
Louisiana
$2,103
302%
$84,120
Maine
$2,175
313%
$84,120
Maryland
$2,049
294%
$81,960
Massachusetts
$1,407
202%
$84,120
Michigan
$2,103
302%
$84,120
Minnesota
$1,407
202%
$23,774-$84,120
Mississippi
$2,103
302%
$84,120
Missouri
$1,407
202%
$84,120
Montana
$2,103
302%
$16,900-$84,120
Nebraska
$1,407
202%
$84,120
Nevada
$2,103
302%
$84,120
New Hampshire
$2,103
302%
$16,824-$84,120
New Jersey
$1,408
202%
$84,120
New Mexico
$1,407
202%
$31,290-$84,120
New York
$2,103
302%
$74,820
North Carolina
$2,103
302%
$84,120
North Dakota
$2,103
302%
$84,120
Ohio
$1,407
202%
$84,120
Oklahoma
$2,103
302%
$84,120
Oregon
$1,407
202%
$16,824
Iowa
Kansas
CRS-40
Community spouse’s minimum
maintenance needs allowance
(monthly protected income)a
% of poverty
Community spouse’s
protected resources
amountsb
State
Income
Pennsylvania
$1,407-$2,103
202%-302%
$16,824- $84,120
Rhode Island
$1,407-$2,103
202%-302%
$16,824-$84,120
South Carolina
$1,662
239%
$66,480
South Dakota
$1,407
202%
$84,120
Tennessee
$1,407
202%
$16,824- $84,120
Texas
$2,103
302%
$16,824-$84,120
Utah
$1,407
202$
$16,824-$84,120
Vermont
$1,407
202%
$84,120
Virginia
$1,406.25-$2,103
202%-302%
$16,824-$84,120
Washington
$1,407-$2,103
202%-302%
$84,120
West Virginia
$1,407-$2,103
202%-302%
$84,120
Wisconsin
$1,875
269%
$84,120
Wyoming
$2,103
302%
$84,120
Source: Congressional Research Survey of Selected Medicaid Eligibility and Post-Eligibility for
Aged, Blind, Disabled (ABD) Groups, November 2000. State reported responses via email, telephone
and fax.
a
Federal law establishes both a floor and a ceiling for the amount of monthly income states must
protect. In 2000, states were required to protect at least $1,406.25 per month (150% of the
federal poverty level) and had the option to protect up to $2,103 per month. States have
flexibility to set the protected income amounts in between this range.
b
Federal law requires states to protect the assets of a couple up to $16,824. States have the option to
protect half of the resources for the community spouse up to $84,120. States can choose a
protected level in between these two amounts. Further, states can elect to have both a floor and
a ceiling, or can collapse the floor and the ceiling into one amount. Where two numbers are
shown, the first is the minimum and the second is the maximum amount. Where one number
is shown, this is the floor and the ceiling.
Post-Eligibility Treatment of Income
Medicaid has another set of rules for treatment of income after a person has
become eligible for coverage and is living in a nursing home, other institution or is
receiving HCBS waiver services while living in the community. These rules apply
to eligible beneficiaries who qualify under a medically needy program or the 300%
rule, and determine how much of the beneficiary’s income must be applied to the cost
of care before Medicaid makes its payment. These rules are commonly referred to
as the post-eligibility rules, or more accurately, the post-eligibility treatment of
income rules.
CRS-41
Personal Needs Allowance (PNA)
For persons in nursing homes and other institutions, Medicaid requires that
states reserve a personal needs allowance (PNA) from a beneficiary’s income. This
is an amount that is considered reasonable to cover various personal care items not
included in the institution’s basic charge, such as clothing, individual preferences on
personal care items (toothpaste and shampoo), social support (telephone, stationary,
etc.), and occasional outings. If a nursing resident enters a hospital, a daily fee must
be paid to the nursing facility to reserve a bed for her return. PNA funds are often
used for this payment. Medicaid law requires that states set aside $30 for an
individual and $60 for a couple for monthly spending on an individuals’ personal
needs, including clothing, etc.39
SSI recipients for whom more than half of their medical bills in an institution
are paid for by Medicaid are also subject to PNA restrictions. These individuals
automatically have their monthly SSI benefit reduced to $30, beginning with the first
full calendar month of residence.40
States have the option of supplementing the federal minimum PNA with state
funds. The PNA amount, therefore, varies by state, with 16 states having no
supplement. Personal Needs Allowances are not adjusted to reflect changes in the
annual cost of living, although two states, Connecticut and Minnesota, increase their
PNA levels annually. Table 8 shows PNA levels by state.
Table 8. Personal Needs Allowance, November 2000
State
Personal Needs Allowance
Alabama
$30
Alaska
$75
Arizona
$76.80
Arkansas
$40
California
$35
Colorado
$50
Connecticut
$52
District of Columbia
$42
Delaware
$70
39
The federal PNA benefit was increased from $25 to $30 a month on July 1, 1988 by the
Omnibus Budget Reconciliation Act of 1987 (OBRA 87). OBRA 87 increased the PNA for
both Medicaid and SSI programs and was the first increase since the SSI Program began in
1974.
40
However, the 1987 Budget Reconciliation Act stipulates that if a physician certifies that
the recipient’s stay in such a medical institution is not likely to exceed 3 months and they
need to continue to maintain a home to which they may return, SSI benefits will not be
reduced and recipients will continue to receive full SSI benefits for up to the first 3 months
of institutionalization.
CRS-42
State
Personal Needs Allowance
Florida
$35
Georgia
$30
Hawaii
$30
Idaho
$30
Illinois
$30
Indiana
$50
Iowa
$30
Kansas
$30
Kentucky
$40
Louisiana
$38
Maine
$40
Maryland
$40
Massachusetts
$60
Michigan
$60
Minnesota
$67
Mississippi
$44
Missouri
$30
Montana
$40
Nebraska
$50
Nevada
$35
New Hampshire
$50
New Jersey
$35
New Mexico
$45
New York
$50
North Carolina
$30
North Dakota
$40
Ohio
$40
Oklahoma
$50
Oregon
$30
Pennsylvania
$30
Rhode Island
$50
South Carolina
$30
South Dakota
$30
Tennessee
$30
Texas
$45
Utah
$45
CRS-43
State
Personal Needs Allowance
Vermont
$47.66
Virginia
$30
Washington
$41.62
West Virginia
$50
Wisconsin
$45
Wyoming
$30
Source: Congressional Research Survey of Selected Medicaid Eligibility and PostEligibility for Aged, Blind, Disabled (ABD) Groups, November 2000. State reported
responses via email, telephone and fax.
Maintenance Needs Allowance for Persons Receiving Home
and Community-Based Care Services
As noted above, states may apply more liberal income eligibility standards, e.g.
the 300% rule, to persons qualifying for community-based waiver services. When
that is the case, beneficiaries may become responsible for paying some portion of the
costs of their care, after deductions (or income disregards) are made for their living
expenses in the community. Table 9 shows amounts of income and resources that
states protected, as of November 2000, for persons receiving waiver services. Any
income above these amounts must be applied toward the cost of their care. Six states
protected less income than the 2000 SSI benefit standard of $512 (Arizona, Illinois,
Maryland, Montana, Nebraska and North Dakota) and three states protected the SSI
benefit level (Indiana, South Carolina and Virginia).
States also have the option of applying spousal impoverishment protections to
the ineligible spouse of a beneficiary receiving services. As of November 2000, 38
states used spousal impoverishment rules for couples living in the community when
one spouse receives waiver services.
CRS-44
Table 9. Maintenance Needs Allowance and Spousal
Impoverishment Rules for HCBS, November 2000
State
Maintenance Needs Allowance
(maximum protected monthly
income)
Spousal Impoverishment Rules
Apply
Alabama
$1,536
no
Alaska
$1,536
yes
Arizona
$204
yes
Arkansas
$1,536
no
California
$600
yes
Colorado
$1,536
yes
Connecticut
$1,392
yes
District of
Columbia
$1,280
yes
Delaware
$1,536
no
Florida
depends on waiver
no
Georgia
$530
yes
Hawaii
Equivalent to income ceiling of
qualifying eligibility pathway plus
$20
yes
Idaho
$796
yes
Illinois
$487
yes
Indiana
$512 for children under 18 or
students 18-21 only
no
Iowa
$1,536
yes
Kansas
$687
yes
Kentucky
$532
yes
Louisiana
$1,536
yes
125% of FPL
no
Maryland
$480
yes
Massachusetts
$522
no
Michigan
$1,536
yes
Minnesota
$700 elderly/$487 disabled
yes (for elderly only)
Mississippi
$1,536
yes
Missouri
$896
yes
Montana
$508
no
Nebraska
$392
yes
Maine
CRS-45
State
Maintenance Needs Allowance
(maximum protected monthly
income)
Nevada
$1,024 (200% of SSI for aged only/
300% of SSI for all other waiver
cases)
yes
depends on waiver
no
New Jersey
$1,536
yes
New Mexico
$1,516
yes
New York
$600
yes
North Carolina
100% of FPL
yes (resources only, do not
assess post-eligibility for HCBS)
North Dakota
$455
yes
Ohio
$1,001
yes
Oklahoma
$1,536
yes
Oregon
$513.70
yes
$1,536 (individuals do not
contribute toward waiver services)
no
Rhode Island
$600
no (spousal impoverishment
rules apply only to assisted
living waiver)
South Carolina
$512
yes
South Dakota
$530
yes
Tennessee
$1,024
no
Texas
$1,563
yes
Utah
$696
yes
Vermont
$766
yes
Virginia
$512 ($1,536 for AIDS waiver)
yes
$696 (depends on waiver)
yes
$1,536
yes
Wisconsin
$616
yes
Wyoming
$1,536
yes
New Hampshire
Pennsylvania
Washington
West Virginia
Spousal Impoverishment Rules
Apply
Source: Congressional Research Survey of Selected Medicaid Eligibility and PostEligibility for Aged, Blind, Disabled (ABD) Groups, November 2000. State reported
responses via email, telephone and fax.
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.