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MEDICAL SERVICES POLICY MANUAL,SECTION E

E 100 FinancialEligibility

AssistedLiving, and PACE MedicareSavings: ARSeniors QMB SMB QI-1 QDWI Equal to orbelow 80% FPL 100% FPL Between100% & 120% FPL 120% but less than 135% FPL 200% FPL Appendix F ARSeniors,QMB, SMB & QI-1: Individual$9,430 Couple $14,130 QDWI: Individual $4000 Couple $6000 Workers with Disabilities Unearned income may notexceed SSI individual benefit plus $20 No resource test PICKLE Under the current SSI/SPA level Appendix S Individual $2000 Widows & Widowers with a Disability (COBRA and OBRA ’87) Under the current SSI/SPA level Appendix S Individual $2000 Widows & Widowers with a Disability and Surviving Divorced Spouses with a Disability (OBRA ’90) Under the current SSI/SPA level Appendix S Individual $2000 DisabledAdult Child (DAC) Under the current SSI/SPA level Appendix S Individual $2000 *May be eligiblefor an additional 5% disregard, MS E-268.

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Page 128

Official source

MEDICAL SERVICES POLICY MANUAL,SECTION E

E 100 FinancialEligibility

AssistedLiving, and PACE MedicareSavings: ARSeniors QMB SMB QI-1 QDWI Equal to orbelow 80% FPL 100% FPL Between100% & 120% FPL 120% but less than 135% FPL 200% FPL Appendix F ARSeniors,QMB, SMB & QI-1: Individual$9,430 Couple $14,130 QDWI: Individual $4000 Couple $6000 Workers with Disabilities Unearned income may notexceed SSI individual benefit plus $20 No resource test PICKLE Under the current SSI/SPA level Appendix S Individual $2000 Widows & Widowers with a Disability (COBRA and OBRA ’87) Under the current SSI/SPA level Appendix S Individual $2000 Widows & Widowers with a Disability and Surviving Divorced Spouses with a Disability (OBRA ’90) Under the current SSI/SPA level Appendix S Individual $2000 DisabledAdult Child (DAC) Under the current SSI/SPA level Appendix S Individual $2000 *May be eligiblefor an additional 5% disregard, MS E-268.