Medicaid Financial Eligibility in Pathways Based on Old Age or Disability in 2022: Findings from a 50-State Survey
% FPL equivalent is presented for comparison purposes only; several states reported that income limits are tied to AFDC limits and not based on a percentage of poverty.
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-Sept. 30, 2022, amended June 27, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf.
States’ survey responses in this section were supplemented with the state plan amendments posted on Medicaid.gov.
The effective income limit in IN is 300% FPL, because the state disregards income in the amount of the difference between 150% FPL and 300% FPL. IN SPA #18-011, § 1915 (i) HCBS, Attachment 2.2-A, page 23g (approved 5/16/19, effective 6/1/19); IN SPA #13-013, § 1915 (i) HCBS, Attachment 2.2-A, page 23g (approved 5/30/14, effective 6/1/14).
The effective income limit in OH is higher because the state disregards income in the amount of the difference between 150% FPL and 300% SSI. Physical health diagnoses include HIV/AIDS, cancer, sickle cell anemia, hemophilia, immune deficiency, cystic fibrosis, end state renal disease, and previous transplant. OH #17-017, § 1915 (i) HCBS, Attachment 3.1-I, page 6-7 (approved 8/23/17, effective 7/1/17).
The effective income limit in MD is higher because the state disregards income in the amount of the difference between 150% FPL and 300% FPL. MD #19-0004, Individuals Receiving State Plan Home and Community-Based Services, (approved 9/5/19, effective 10/1/19) (p. 14 of pdf).
AL SPA #21-0005-A, Eligibility (approved 6/14/21, effective 4/1/21).
CT#21-0001-A, Eligibility (approved and effective 8/16/21).
CT’s increase reflects changes to the underlying financial methodology which will tie cash assistance payments to a percentage of the federal poverty level and in turn set the Medicaid income limit for seniors and people with disabilities at 143% of the cash assistance payment, along with a $409/month unearned income disregard.
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.
Under federal SSI rules, there is a general income disregard of $20 per month. Earned income is subject to an additional disregard of $65 plus half of the remaining amount.
Certain assets, such as an individual’s home, one car used for household transportation, and a certain amount of funds for prepaid burial expenses, are excluded from the SSI asset limit.
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 Appendix). 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).
42 U.S.C. § § 1396a (a)(10)(A)(ii)(XV), (XVI); 1396o (g).
See, e.g., KFF, Benefits and Cost-sharing for People with Disabilities in Medicaid and the Marketplace (Oct. 2014).
An antiquated term in the statute.
For more about HCBS waivers, see KFF, Medicaid Home and Community-Based Services: People Served and Spending During COVID-19 (March 2022), ; KFF, State Policy Choices About Medicaid Home and Community-Based Services Amid the Pandemic (March 2022).
42 U.S.C. § § 1396a (a)(10)(C); 1396d (a)(iii), (iv), (v).
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).
Unless the state had a Section 1115 waiver that used cost savings to expand coverage.
For more information on medically needy eligibility and how to calculate spend down, see KFF, The Medically Needy Program: Spending and Enrollment Update (Dec. 2012),
100% FPL for an individual in Hawaii is $1,303/month in 2022.
42 U.S.C. § § 1396a (a)(10)(A)(ii)(X); 1396a (m).
42 U.S.C. § § 1396a (a)(10)(A)(ii)(XIX); 1396a (cc)(1).
Section 1915 (i) also allows states to provide an HCBS benefit package, as a state plan option instead of a waiver, to people who are eligible for Medicaid through another eligibility pathway.
42 U.S.C. § 1396a (a)(10)(A)(ii)(XXII).
In Olmstead, the Supreme Court held that the unjustified institutionalization of people with disabilities violates the Americans with Disabilities Act. KFF, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid: 15 Years After the Supreme Court’s Olmstead Decision (June 2014).
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 KFF, Medicaid Home and Community-Based Services: People Served and Spending (March 2022); KFF, State Policy Choices About Medicaid Home and Community-Based Services Amid the Pandemic (March 2022).
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).
42 U.S.C. § 1396p (d)(4)(A).
42 U.S.C. § 1396p (d)(4)(C).
42 U.S.C. § 1396p (f).
42 U.S.C. § 1396a (q).
These individuals are eligible for Medicaid via 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.
42 C.F.R. § 435.726 (c). States use different methodologies to determine the monthly maintenance needs allowances for HCBS enrollees. Most states allow individuals to deduct their uncovered medical bills from income.
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 KFF, Potential Changes to Medicaid Long-Term Care Spousal Impoverishment Rules: States’ Plans and Implications for Community Integration (Feb. 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, 2022 SSI and Spousal Impoverishment Standards (Nov. 23, 2021).
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.
The spousal impoverishment rules were extended through March 31, 2019 in the Medicaid Extenders Act of 2019, § 3, Pub. L. No. 116-3 (Jan. 24, 2019); through September 30, 209 in the Medicaid Services Investment and Accountability Act of 2019, § 2, Pub. L. No. 116-16 (April 18, 2019); through December 31, 2019 in the Sustaining Excellence in Medicaid Act of 2019, Pub. L. No. 116-39 (Aug. 8, 2019); through May 22, 2020 in the Further Consolidated Appropriations Act, Pub. L. No. 116-94 (Dec. 20, 2019); and through September 30, 2023 in the Consolidated Appropriations Act of 2021, Pub. L. No. 116-260 (Dec. 27, 2020).