Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey
Issue Brief
Kaiser Family Foundation, Medicaid Enrollment by Age (FY 2013).
Kaiser Family Foundation, Medicaid Restructuring Under the American Health Care Act and Nonelderly Adults with Disabilities (March 2017), https://www.kff.org/medicaid/issue-brief/medicaid-restructuring-under-the-american-health-care-act-and-nonelderly-adults-with-disabilities/.
Kaiser Family Foundation, Medicaid’s Role for Children with Special Health Care Needs: A Look at Eligibility, Services, and Spending (June, 2019), https://www.kff.org/medicaid/issue-brief/medicaids-role-for-children-with-special-health-care-needs-a-look-at-eligibility-services-and-spending/.
For state-level data about Medicaid eligibility through poverty-related pathways, see Kaiser Family Foundation, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey (March 2019), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2019-findings-from-a-50-state-survey/.
Medicaid eligibility pathways based on old age or disability include two general components: financial eligibility rules that limit income and sometimes assets and functional eligibility rules that determine the degree of a person’s need for services and supports. State variation in functional eligibility criteria associated with these pathways is beyond the scope of this brief.
Arkansas and Rhode Island did not respond to the survey. Data for these two states were obtained from state Medicaid agency websites and Medicaid.gov.
42 U.S.C. § 1396a (a)(10)(A)(i)(II); but see 42 U.S.C. § 1396a (f).
The couple rate applies when both individuals qualify for SSI.
$771 for an individual and $1,157 for a couple in 2019.
Section 209 (b) states must allow SSI beneficiaries to establish Medicaid eligibility through a spend-down by deducting unreimbursed out-of-pocket medical expenses from their countable income (described later in this brief). Section 209 (b) states also must provide Medicaid to children who receive SSI and who meet the financial eligibility rules for the state’s Aid to Families with Dependent Children program as of July 16, 1996. 42 U.S.C. § 1396a (f); see also 42 U.S.C. § 1396a (a)(10)(C)(i)(III) and (ii); 42 C.F.R. § 435.121 (d).
The federal SSI rules also include additional disregards for earned income. See Box 1 in the text.
100% FPL for an individual in 2019 is $1,041/month in the continental U.S. 100% FPL for an individual in Hawaii is $1,163 in 2018, and $1,198 in 2019.
42 U.S.C. § § 1396a (a)(10)(A)(ii)(X); 1396a (m).
42 U.S.C. § § 1396a (a)(10)(C); 1396d (a)(iii), (iv), (v).
$500/month for an individual in 2019. States reported a single medically needy income limit across covered populations.
Additionally, four states (CT, LA, VA, and VT) vary medically needy income limits by region to account for variation in cost of living in different geographic areas.
States’ medically needy income limits are so low because they are tied to the Aid to Families with Dependent Children (AFDC) payment levels that were in place in 1996. Federal rules require medically needy income levels to be no higher than 133 1/3% of the state’s maximum AFDC payment level for a family of two without any income or assets as of July 16, 1996. States can raise their medically needy income limits if they increase their TANF income standards, but few states have done so (TANF replaced AFDC in 1996). 42 U.S.C. § § 1396b (f)(1)(B)(i); 1396u-1 (b), (f)(3).
$771/month in 2019.
Unless the state had a Section 1115 waiver that used cost savings to expand coverage.
$1,436/month for an individual in 2019.
For more information on medically needy eligibility and how to calculate spend down, see Kaiser Family Foundation, The Medically Needy Program: Spending and Enrollment Update (Dec. 2012), https://www.kff.org/medicaid/issue-brief/the-medicaid-medically-needy-program-spending-and/.
Another four states report using one or six months, with two of those states (VA and VT) specifying that a six month period is used for individuals living in the community.
An antiquated term in the statute.
$2,313/month for an individual in 2019.
42 U.S.C. § 1396a (e)(3); 42 C.F.R. § 435.225.
La. H.B. 199 Enrolled (2019 Regular Session), http://www.legis.la.gov/legis/BillInfo.aspx?s=19RS&b=HB199&sbi=y; La. Legislative Fiscal Office Fiscal Note on HB 199 Re-Engrossed with Senate Committee Amendments (May 31, 2019), http://www.legis.la.gov/legis/ViewDocument.aspx?d=1140097.
For more about HCBS waivers, see Kaiser Family Foundation, Medicaid Home and Community-Based Services Enrollment and Spending (April 2019), https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/; Kaiser Family Foundation, Key State Policy Choices About Medicaid Home and Community-Based Services (April 2019), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/; Kaiser Family Foundation, Key Questions About Medicaid Home and Community-Based Services Waiver Waiting Lists (April 2019), https://www.kff.org/medicaid/issue-brief/key-questions-about-medicaid-home-and-community-based-services-waiver-waiting-lists/.
CMS, TennCare II Special Terms and Conditions, #11-W-00151/4 at paragraph 20 and Table 1a (Dec. 16, 2016-June 30, 2021), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/tn/tn-tenncare-ii-ca.pdf. As of October-December 2018, Tennessee covered just under 1,600 children in this pathway. TennCare II, Section 1115 Quarterly Report for the period October – December 2018, Table 2, p. 3 (EG7E Expan Child, Type 3 Demonstration Population), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/tn/TennCare-II/tn-tenncare-ii-qtrly-rpt-oct-dec-2018.pdf. Those with income less than 211% FPL are covered with CHIP funds.
This pathway covers children up to age 21 and also includes children who do not currently meet, but are at risk of meeting, an institutional level of care. TennCare II Special Terms and Conditions, supra. n.28 at paragraph 22 (f), p. 36 and Table 2c.
Tenn. General Assembly, Amendments No. 1-1 and 2 to H.B.0498, http://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=SB0476.
Tenn. General Assembly Fiscal Review Committee, Fiscal Memorandum HB 498-SB 476 (April 29, 2019), http://wapp.capitol.tn.gov/apps/BillInfo/Default.aspx?BillNumber=SB0476.
42 U.S.C. § § 1396a (a)(10)(A)(ii)(XIX); 1396a (cc)(1). 300% FPL is $5,333/month for a family of three in 2019.
Under Massachusetts’ waiver, state plan “base populations” include all infants under age one (based solely on income) through 200% FPL and children with disabilities under age 19 through 150% FPL. Waiver expansion populations include “higher income children with disabilities” with no income limit. CMS Special Terms and Conditions, MassHealth Medicaid Section 1115 Demonstration, #11-W-00030/1,Table A, p. 10, 16, 21 (approved July 1, 2017-June 30, 2022, amended June 27, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf.
$267/month for a family of three at 300% FPL in 2019.
MassHealth Medicaid Section 1115 Demonstration, supra. n. 33 at 21. Monthly premiums are $12 for 151-200% FPL, $20 for 201-250% FPL, $28 for 251-300% FPL, and at higher amounts for those above 300% FPL. MassHealth CommonHealth at p. 30-31, https://www.mass.gov/files/documents/2016/07/my/aca-1-english-mb-mh-commonhealth.pdf.
42 U.S.C. § § 1396a (a)(10)(A)(ii)(XV), (XVI); 1396o (g).
See, e.g., Kaiser Family Foundation, Benefits and Cost-sharing for People with Disabilities in Medicaid and the Marketplace (Oct. 2014), https://www.kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/.
$2,602/month for an individual in 2019.
$833/month for an individual in 2019.
One state, AR, did not respond to this survey question.
42 U.S.C. § 1396a (a)(10)(A)(ii)(XXII).
Indiana offers Section 1915 (i) services targeted to multiple populations with mental illness (differentiated by age) and uses Section 1915 (i) as an independent pathway to Medicaid eligibility for one of these populations. Findings in this section have been supplemented by data reported from KFF’s annual Medicaid HCBS survey. See Kaiser Family Foundation, Key State Policy Choices About Medicaid Home and Community-Based Services (April 2019), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/.
Physical health diagnoses include HIV/AIDS, cancer, sickle cell anemia, hemophilia, immune deficiency, cystic fibrosis, end stage renal disease, and previous transplant. Ohio #17-017 § 1915 (i) State plan HCBS (effective June 1, 2017, approved Aug. 23, 2017), https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/OH/OH-17-017.pdf.
Section 1915 (i) allows states to offer HCBS as part of their Medicaid state plan benefit package instead of through a waiver.
Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision (May 13, 2019).
17of 37: AZ, AR (covers seniors only), CA, DC, HI, IL, IN, ME, MA, MI, MN, NE, NJ, PA, RI, UT, and VA.
4 of 14: FL, NC, OK, and SC.
17 of 37: AR, CA, CT, DC, HI, IL, IA, KY, LA, ME, MD, MA, MI, MN, MT, NE, NH, NJ, NY, ND, PA, RI, UT, VT, VA, WA, and WV.
5 of 14: FL, GA, KS, NC, and WI. (TN and TX cover medically needy pregnant women and children but not seniors and people with disabilities.)
16 of 37: AK, CO, DE, DC, ID, IA, ME, MA, MN, NE, NV, NH, NY, RI, VT, and WV.
Excludes states with Katie Beckett-like waivers, in which enrollment can be capped.
5 of 14: GA, MS, OK, SC, and SD.
36 of 37, all except HI.
9 of 14; all except AL, MO, OK, SC, and TN.
Kaiser Family Foundation, Medicaid Home and Community-Based Services Enrollment and Spending (April 2019), https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/.
In Olmstead, the Supreme Court held that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act. Kaiser Family Foundation, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014), https://www.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/.
$2,313/month for an individual in 2019.
Those in institutions must have resided there for at least 30 days. 42 U.S.C. § 1396a (a)(10)(ii)(V) and (VI).
States also use § 1915 (c) and § 1115 waivers to expand financial eligibility for HCBS. See generally Kaiser Family Foundation, Medicaid Home and Community-Based Services Enrollment and Spending (April 2019), https://www.kff.org/medicaid/issue-brief/medicaid-home-and-community-based-services-enrollment-and-spending/; Kaiser Family Foundation, Key State Policy Choices About Medicaid Home and Community-Based Services (April 2019), https://www.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/.
See Miller v. Ibarra, 746 F. Supp. 19 (D. Colo. 1990).
This option is not available in medically needy states unless they do not offer nursing facility services to medically needy populations. 42 U.S.C. § 1396p (d)(4)(B).
CO reports unspecified regional caps. MS caps trust income for those in institutions at the nursing facility private pay rate and at $3,035 for those receiving HCBS. MO reports that caps vary.
42 U.S.C. § 1396p (d)(4)(A).
42 U.S.C. § 1396p (d)(4)(C).
Two other states (CT and MO) have cap policies that vary by program.
One state (Hawaii) reported that its ABLE program was enacted but not yet active. For more information about ABLE Accounts, see generally CMS, State Medicaid Director Letter #17-002, Implications of the ABLE Act for State Medicaid Programs (Sept. 7, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17002.pdf. Two states (AK and ID) did not respond to this question.
Income earned in ABLE accounts generally is not subject to federal income tax, similar to Section 529 college savings accounts. 26 U.S.C. § 529A. A person with a disability may open an account in the ABLE program in their state of residence or in another state, if permitted by that state’s program; the majority of state ABLE programs allow out-of-state enrollment. ABLE National Resource Center, Step #5 –How Do I Enroll? (last accessed May 8, 2019), http://ablenrc.org/step-5-how-do-i-enroll.
$12,490/year for an individual in 2019.
See generally IRS, ABLE Accounts – Tax Benefit for People with Disabilities (Feb. 4, 2019), https://www.irs.gov/government-entities/federal-state-local-governments/able-accounts-tax-benefit-for-people-with-disabilities.
This amount is based on state tax laws.
80 Fed. Reg. 35602, 35608 (June 22, 2015), https://www.govinfo.gov/app/details/FR-2015-06-22/2015-15280.
$585,000 minimum and $878,000 maximum in 2019.
42 U.S.C. § 1396a (q).
42 C.F.R. § 435.726. States use different methodologies to determine the monthly maintenance needs allowances for HCBS beneficiaries. For example, Maryland allows individuals to deduct housing costs from income. Most states allow individuals to deduct their uncovered medical bills from income.
Except for seniors.
Such individuals are eligible for Medicaid by reason of a Section 1915 (c) HCBS waiver because they would be eligible under the Medicaid state plan if institutionalized, meet an institutional level of care, and would be institutionalized if not receiving waiver services. 42 U.S.C. § 1396a (a)(10)(A)(ii)(VI). They sometimes are referred to as the “217-group,” because they are described in 42 C.F.R. § 435.217.
42 C.F.R. § 435.726 (c).
Same amount through June 2019. While the community spouse maximum income maintenance allowance and minimum and maximum asset allowances are adjusted each January, the community spouse minimum monthly maintenance needs allowance is adjusted as of July 1st. CMCS Informational Bulletin, Updated 2019 Spousal Impoverishment Standards (May 30, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib053019.pdf . Most states reported this amount as $2,058, but CMS lists the federal minimum as $2,057.50. Starting July 2019, $2,113.75 per month for all states except Alaska and Hawaii. $2,641.25 per month in Alaska and $2,432.50 per month in Hawaii.
$3,160.50 per month in 2019.
42 U.S.C. § 1396r-5 (a)(1). The rules permit (and sometimes require) that a married individual seeking Medicaid LTSS whose spouse is not institutionalized is treated differently for financial eligibility purposes from other individuals seeking Medicaid LTSS. 42 U.S.C. § 1396r-5 (a)(2). For more information, see Kaiser Family Foundation, Potential Changes to Medicaid Long-Term Care Spousal Impoverishment Rules: States’ Plans and Implications for Community Integration (Feb. 2019), https://www.kff.org/report-section/potential-changes-to-medicaid-long-term-care-spousal-impoverishment-rules-states-plans-and-implications-for-community-integration-issue-brief/.
$126,420 in 2019.
$25,284 in 2019.
Data in this paragraph and the following paragraph were previously reported in Kaiser Family Foundation, Potential Changes to Medicaid Long-Term Care Spousal Impoverishment Rules: States’ Plans and Implications for Community Integration (Feb. 2019), https://www.kff.org/report-section/potential-changes-to-medicaid-long-term-care-spousal-impoverishment-rules-states-plans-and-implications-for-community-integration-issue-brief/.
According to Illinois’ approved waiver documents, Illinois currently applies the rules to 7 of its 9 HCBS waivers: persons with disabilities waiver (approved 7/12/16); elderly waiver (approved 11/1/16); children and adults with I/DD waiver (approved 7/1/17); residential waiver for children and young adults with I/DD (approved 7/1/17); medically fragile children’s waiver (approved 9/1/17); supportive living waiver for seniors and people with disabilities (approved 10/31/17); adult I/DD waiver (approved 12/11/17). This information is not provided for 2 waivers: HIV/AIDS waiver (approved 1/21/14) and brain injury waiver (approved 7/1/17).
Specifically, states could opt to apply the rules to individuals who are eligible for Medicaid by reason of a Section 1915 (c) HCBS waiver, under 42 U.S.C. § 1396a (a)(10)(A)(ii)(VI) (describing individuals who would be eligible under the Medicaid state plan if institutionalized, meet an institutional level of care, and would be institutionalized if not receiving waiver services, sometimes referred to as the “217-group,” because they also are described in 42 C.F.R. § 435.217). 42 U.S.C. § 1396r-5 (h)(1)(A).
Section 2404 also expanded the spousal impoverishment rules to the Section 1915 (i) HCBS state plan option, Community First Choice (CFC) attendant care services and supports, and individuals eligible through a medically needy spend down.
Medicaid Extenders Act of 2019, § 3, Pub. L. No. 116-3 (Jan. 24, 2019), https://www.congress.gov/bill/116th-congress/house-bill/259.
Medicaid Services Investment and Accountability Act of 2019, § 2, Pub. L. No. 116-16 (April 18, 2019), https://www.congress.gov/bill/116th-congress/house-bill/1839/.
After the initial report releasing this data, Kaiser Family Foundation, Potential Changes to Medicaid Long-Term Care Spousal Impoverishment Rules: States’ Plans and Implications for Community Integration (Feb. 2019), https://www.kff.org/report-section/potential-changes-to-medicaid-long-term-care-spousal-impoverishment-rules-states-plans-and-implications-for-community-integration-issue-brief/, Montana reported that its status changed from “undecided” to “yes.”
AR will apply the rules to its waivers for seniors/adults with physical disabilities and assisted living but not to its waivers for autism and intellectual/developmental disabilities. Waiver approval documents on Medicaid.gov indicate that AR’s excluded waivers do cover the 217-group.
IL plans to apply the rules in full to 1 waiver: supportive living waiver for seniors and adults with physical disabilities (approved 10/23/17). IL plans to apply the rules for financial eligibility but not PETI to 2 waivers: persons with disabilities waiver (approved 7/12/16) and elderly waiver (approved 11/1/16). IL does not plan to apply the rules to 4 waivers: children and adults with I/DD waiver (approved 7/1/17); residential waiver for children and young adults with I/DD (approved 7/1/17); medically fragile children’s waiver (approved 9/1/17); and adult I/DD waiver (approved 12/11/17). This information is not provided in for 2 waivers, neither of which cover the 217-group: HIV/AIDS waiver (approved 1/21/14) and brain injury waiver (approved 7/1/17).
MN plans to apply the rules to its elderly waiver (approved 7/1/18). MN does not plan to apply the rules to its brain injury waiver (approved 6/1/16); community access for disability inclusion waiver (approved 6/1/16;) DD waiver (approved 10/27/17); and community alternative care waiver (approved 4/1/18).
Waiver approval documents on Medicaid.gov indicate that ME’s seven waivers do cover the 217-group.
Dual eligible beneficiaries qualify for both Medicare and Medicaid. All dual eligible beneficiaries qualify for Medicaid assistance with their Medicare out-of-pocket costs through one of the Medicare Savings Programs (MSP) described in this section. Additionally, Medicare beneficiaries who independently qualify for Medicaid through another poverty or disability-related pathway also receive full Medicaid benefits. These “full duals” may receive Medicaid services that Medicare does not cover, such as LTSS, eyeglasses, dental care, or hearing aids. Medicare beneficiaries who qualify only for an MSP are known as “partial duals” and receive Medicaid assistance only with Medicare premiums and/or cost-sharing. See generally Kaiser Family Foundation, Medicaid’s Role for Medicare Beneficiaries (Feb. 2017), https://www.kff.org/medicaid/issue-brief/medicaids-role-for-medicare-beneficiaries/.
Medicare Part D, which covers prescription drugs, has financial assistance for low-income beneficiaries (the Low-Income Subsidy program) built into the program instead of being available through Medicaid. See generally, Kaiser Family Foundation, An Overview of the Medicare Part D Prescription Drug Benefit (Oct. 2018), https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/.
$1,364 in 2019. Medicare Part A also requires co-insurance for hospital stays over 60 days. Most Medicaid beneficiaries qualify for Part A without a premium. CMS Fact Sheet, 2019 Medicare Parts A & B Premiums and Deductibles (Oct. 12, 2018), https://www.cms.gov/newsroom/fact-sheets/2019-medicare-parts-b-premiums-and-deductibles.
$135.50 in 2019. Id.
$185 in 2019. Id.
Id.
42 U.S.C. § 1396d (p). $1,041/month for an individual and $1,409/month for a couple in 2019.
42 U.S.C. § 1396a (a)(10)(E)(iii).
$1,249/month for an individual and $1,691/month for a couple in 2019.
42 U.S.C. § 1396a (a)(10)(E)(iv). $1,405/month for an individual and $1,902/month for a couple in 2019.
DC’s effective QMB income limit is 300% FPL ($3,035 per month for an individual in 2018, $3,123/month in 2019) after applying income disregards, which means that all MSP beneficiaries in DC receive QMB premium and cost-sharing assistance, and none are covered in the less generous SLMB or QI programs.
42 C.F.R. § 435.916 (b); see also Kaiser Family Foundation, The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities (April 2014), https://www.kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.
RI did not respond to either of these survey questions. CT did not respond to the reconsideration period question.
AR elects this option only for MSP pathways. RI did not respond to this question.
Compare Appendix Table 10 with Kaiser Family Foundation, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey, Table 13, (March 2019), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2019-findings-from-a-50-state-survey/.
NM offers a reconsideration period for waivers only. CT and RI did not respond to this question.
42 C.F.R. § 435.916 (a)(3).
84 Fed. Reg. 19961-19963 (May 7, 2019), https://www.federalregister.gov/documents/2019/05/07/2019-09106/request-for-comment-on-the-consumer-inflation-measures-produced-by-federal-statistical-agencies.