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Medicaid Eligibility
Allen Bryan, Centers for Medicare and Medicaid (CMS)Bethany Hamm, MaineCare
Marybeth McCaffrey, Vermont AHS, Economic Services Division
June 2009
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Section 2: Medicaid Eligibility ProcessTable of Contents
Category General Eligibility Factors, Other Than
Category Financial Eligibility Factors Eligibility Determination ProcessCoverage-Medicaid and SCHIP Benefits
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Category
Disability
Aged
Blind
Children
Parent/Caretaker Relative
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General Eligibility Factors Other Than Category
After establishing age or disability category, other eligibility factors need to be determined U.S. Citizenship and identity (n/a to SSI, SSDI,
Medicare recipients Residency Who is living with applicant? What resources are owned by applicant and
family? How much income is received by applicant and
family? Retroactive coverage for up to 3 months before
month of application provided all eligibility requirements met 4
Financial Eligibility Factors
Key terms
Financial responsibility
Methodologies
Standards
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Financial Eligibility Factors: Key Terms
Federal Poverty Level (FPL) Income tests based on FPL FPL is adjusted annually according to the cost of living
Medically Needy Income Level (MNIL) Levels are based on law and cannot exceed 133 1/3% of
1931 income standards Compares a group’s countable income to MNIL to
determine financial eligibility for Medicaid
Spenddown Groups who fail MNIL will have income Spenddown to meet
before Medicaid services are covered Similar to deductible associated with medical insurance Usually for six month period
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Financial Eligibility Factors: Financial Responsibility
Whose income and resources to count?
Very challenging to analyze Household composition? Which family members are requesting
coverage?
General rules Parents are financially responsible for their
minor children Spouses are financially responsible for each
other 7
Financial Eligibility Factors: Methodologies
What income and resources are countable vs. excludable?
Resource methodologies Burial funds Term life insurance Personal property (not real property) Home One car Annuities are special
Income methodologies Excluded income (e.g. gifts, food stamp benefits, senior
companion) Countable income
Disregarded income ($20) Deductions from countable income (varies)
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Financial Eligibility Factors: Standards
Resource standards$2000 for individual$3000 for group of two
Income standards
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Income StandardsEffective 1/2009
1 2 3 4 5 6 7 8 Asset Limit
Infants up to age 1185%
$1670 $2247
$2823
$3400 $3976
$4553
$5130
$5706
NONE
Age 1 through Age 5133%
$1201 $1615
$2030
$2444 $2859
$3273
$3688
$4102
NONE
Age 6 through Age 18 125%
$1129 $1518
$1908
$2297 $2687
$3077
$3466
$3856
NONE
SCHIP & Pregnant Women200%
$1805 $2429
$3052
$3675 $4922
$4922
$5545
$6169
NONE$2000NONE
Age 1 –Age 18150%
$1354 $1822
$2289
$2757 $3224
$3692
$4159
$4627
NONE
Age 19-20 (150%)Parents 100-150%0-100%
$1354 $1822
$2289
$2757 $3224
$3692
$4159
$4627
$2000
SSI-Related Medicaid(100%)
$903 $1215
$2000$3000
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Eligibility Determination Process
Takes into account category, general eligibility factors and financial eligibility factors (previous 3 sections)
Determines whether person meets eligibility coverage for any coverage group
Based on income, person may need to contribute in order to enroll or access certain coverage Cost sharing (e.g. may be required for
prescription coverage) Premiums (e.g. may be required before person
can be enrolled Deductibles
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Coverage-Medicaid & SCHIP Benefits
Medicaid & SCHIP offer mandatory and optional services
States have latitude to offer optional services
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Contact Information
Allen Bryan [email protected]
Bethany [email protected]
Marybeth McCaffrey [email protected]
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