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This chapter of the manual provides information regarding the Medicaid and Hoosier Healthwise program. It also defines each specific Medicaid category under which a person/family can qualify. Additionally, it explains the scope of coverage offered under each category. The Medicaid program has categorical eligibility requirements which must be met in order to receive assistance. These requirements are discussed in detail in Chapter 2400 - Non-Financial Eligibility Requirements. The main sections in this chapter include: • Categories of Assistance (Section 1600). • Medical Assistance for the Aged, Blind, & Disabled (Section 1605). • Hoosier Healthwise (Section 1610).
There are 35 categories under which individuals may be eligible for Medicaid coverage. The method used to determine income eligibility (Modified Adjusted Gross Income MAGI/non- MAGI), the type of coverage (traditional fee-for-service or managed care), and the scope of the benefits provided all vary based on the category under which individuals are eligible. (See Chapters 3200 and 3400 for an explanation of MAGI methodology.) The following table lists all of the Medicaid coverage categories, eligibility criteria for each category, the type of benefit package provided, and whether MAGI methods are applied to determine income eligibility. Indiana Medicaid Hierarchy 05052025.p
Medicaid coverage is available to individuals who are aged, blind, or disabled. The scope of coverage varies depending upon the specific category under which an individual qualifies. The categories and scope of coverage are explained in the following sections. As of April 2015, individuals eligible in MED 1 categories who are not in an institution or on a waiver and who are not eligible for Medicare will be enrolled in Hoosier Care Connect (HCC), a coordinated health care program. Hoosier Care Connect members will have to select a managed care entity (MCE) that will help coordinate care with the members’ providers. Care coordination is individualized based on a member’s assessed level of need determined through a health screening. Individuals in MED 1 who are eligible for Medicare and those who reside in institutions or are on a HCBS Waiver will receive Traditional fee-for-service coverage.
This category is identified in the eligibility system as MASI. To be eligible for MASI Medicaid, an individual must be determined to be disabled by the Social Security Administration. When determined SSI disabled and receiving SSI payments, the proper category of assistance is MASI. MASI is based on categorical eligibility and does not have a budget or redetermination. It is a full coverage category with no cost sharing and is at the top of the Medicaid hierarchy, therefore, it should not be replaced with any other category of medical coverage. MASI should be given only based on information received via SDX Interface from the Social Security Administration. The SDX Payment Information page displays the detailed payment status codes for MASI budgeting. The "Payment status code" indicates if an individual is receiving any dollar amount (SSI benefits) and the "Medicaid Eligibility Code" indicates if the SSI applicant is eligible for Federally administered Medicaid coverage (MASI). There are several codes received from SSA via SDX interface, however only one will form SSI. Please see below for detailed information: This population receives SSI payments: • Federally administered Medicaid coverage should be continued regardless of payment status code (1619(b) participants) • This population may or may not be receiving SSI payments: • Goldberg/Kelly payment continuation • Eligible for Medicaid (N24 Payment Status Only) • Eligible for Medicaid (1634 States Only) • All the remaining listed codes are not eligible for MASI budgeting: • REFUSED TO ASSIGN RIGHTS TO TPL • DEEMING WAIVED, CHILD UNDER A STATE HOME CARE PLAN • REFERRED TO THE STATE FOR MEDICAID DETERMINATION DUE TO ENTITLEMENT OR INCREASE IN DAC BENEFITS UNDER T2 • ELIGIBLE UNDER STATE DETERMINATION (OBSOLETE) • TITLE VIII SPECIAL VETERANS BENEFIT RECEIPIENT • INELIGIBLE PER STATE DETERMINATION (OBSOLETE) • DRUG ADDICITON AND/OR ALCOHOLISM (OBSOLETE) • MEDICAID QUALIFYING TRUST MAY EXIST • REFERRED TO STATE FOR DETERMINATION (1634 STATES) - FEDERAL DETERMINATION NOT POSSIBLE • STATE DETERMINATION - NOT SSA RESPONSIBILITY • WIDOW(ER) - 1634 STATES If the worker questions whether MASI is the correct category, they should contact Helpdesk/PAL rather than open MASI without the correct SSA determination. If a person has deemed SSI eligibility but is not receiving payments because another SSA benefit amount is more than the maximum SSI amount (such as disabled adult children members), these members should be determined for MED 1 eligibility under normal income and resource rules. The maximum SSI payment amount should be entered into as SSI income, and any excess above that amount should be entered as Social Security income. This will cause the income to be properly counted in the budget for all programs. This would apply to some widow/ers (see 2414.10.20) and Disabled Adult Children (see 2414.10.10).
This category is identified in IEDSS as MA A. To be eligible in this category, an individual must be age 65 or older.1 A person is categorically eligible for MA A beginning with the month they turn 65. The full range of Medicaid covered services is available to recipients in the MA A category except for aliens who are eligible for emergency services only.
This category is identified in IEDSS as MA B. To be eligible in this category an individual must meet the definition of blindness set forth in State regulation. The definition is the same as that of the SSI program.2 The full range of Medicaid covered services is available to recipients in the MA B category, except for aliens who are eligible for emergency services only.
This category is identified in IEDSS as MA D. To be eligible under this category, individuals must be substantially impaired as set forth in the definition of disability in State law.3 The full range of Medicaid covered services is available to receipts in the MA D category except for aliens who are eligible for emergency services only.
This category is identified in IEDSS as MA R. To be eligible for Residential Care Assistance Program-related Medicaid, an individual must: • Be approved for Room and Board Assistance (RBA). • Be aged, blind, or disabled. The aged, blind, and disabled requirements for RCAP- related Medicaid are the same as those for RCAP.4 • The full range of Medicaid covered services is available to recipients in the MA R category.
MEDWorks – Medicaid for Employees with Disabilities – consists of two categories identified in IEDSS as MADW and MADI. A federal law known as the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIA) added two new optional Medicaid categories designed to remove barriers to employment for persons with disabilities by providing access to health care. Effective July 1, 2002, Indiana’s Medicaid Program was expanded to cover these categories with the enactment of P.L. 287-2001. MADW is the basic MEDWorks category for individuals who meet the Medicaid definition of disability without regard to the person’s employment. MADI is the medically improved category for persons who lose eligibility in the basic category because of an improvement in their medical condition which although is not a medical recovery, is improved to the extent that the Disability definition for the basic category is no longer met.5 To be eligible, individuals must be aged 16-64. Depending on their income, some MEDWorks members must pay premiums. All members pay the regular Medicaid co-payments.
This category is identified in IEDSS as MA L. To be eligible in this category an individual must be entitled to Medicare Part A.6 There is no other blindness or disability requirement for the QMB category. Medicaid coverage under QMB is limited to payment of the following:7 • The monthly premium for Medicare Part B • The monthly premium for Premium Hospital Insurance under Medicare Part A for individuals not entitled to free Part A • Medicare Parts A and B deductibles and co-insurance. An individual can be simultaneously eligible for QMB and any other full coverage MA.
This category is identified in IEDSS as MA J. To be eligible in this category, an individual must be entitled to Medicare Part A.8 There is no other blindness or disability requirement for the Specified Low-Income Medicare Beneficiary (SLMB) category. Medicaid coverage under SLMB is limited to payment of the Medicare Part B premium.9 An individual can be simultaneously eligible for SLMB and any other full coverage MA category.
This category is identified in IEDSS as MA G. To be eligible in this category, an individual must have lost or will lose premium-free Medicare Part A coverage due to his employment status.10 Medicaid coverage under this category is limited to payment of the monthly premium for Medicare Part A.11 An individual is not eligible under this category if they are eligible for Medicaid under any other category.
This category is identified in IEDSS as MA I. To be eligible in this category, an individual must be entitled to Medicare Part A.12 There is a cap amount for QIs each year. MA I pay the Medicare Part B premium.13 An individual eligible under any other Medicaid category cannot be eligible as a QI.
Table 1. Medicare Savings Program Aid Categories Aid Category in IED Benefit Name/Package Minimum Federal Income Limit Indiana’s Income Limit (more generous in most cases) Income Disregard Benefit Can Co- Exist with Full Medicaid category (Full Dual)? Comments MA L Qualified Medicare Beneficiary, QMB 100% FPL 150% FPL $20 general income disregard, $65 + ½ earned income disregard (example: earns $1,065 from a job, we deduct $65 and ½ of the income, and count only $500 of the earned income) Pays Part A & B premiums, coinsurance, and deductibles Yes MA L/QMB can be open along with full Medicaid or can be open alone (partial dual). MA J Specified Low- Income Medicare Beneficiary, SLMB 120% FPL 170% FPL $20 general income disregard, $65 + ½ earned income disregard (example: earns $1,065 from a job, we deduct Pays Part B premiums only Yes MA J/SMLB can be open along with full Medicaid or can be open alone (partial dual). $65 and ½ of the income, and count only $500 of the earned income) MA I Qualified Individual, QI 135% FPL 185% FPL Note: SSA COLA increases go into effect Jan. 1 of each year; we ignore the increase in Social Security income until new FPL amounts go into effect in March 1 of each year. Pays Part B premiums only No All MA I/QI members are partial duals only MA G Qualified Disabled & Working Individuals, QDWI 200% FPL 200% FPL Note: SSA COLA increases go into effect Jan. 1 of each year; we ignore the increase in Social Security income until new FPL amounts go into Pays Part A premiums only No All MA G/QDWI members are partial duals only effect in March 1 of each year.
For the correct Medicaid budget to be applied, it is important to select the correct facility type on the Facility Details screen in the eligibility system (if applicable). If it is unclear what type of facility an individual resides in, it must be verified. This can be completed by contacting the individual, authorized representative or facility. The selections below will build the SIL budget in the eligibility system: • Developmentally Disabled or Developmental Disability • Nursing Facility/Long Term Care • Hospital • Psychiatric Hospital • CRF/DD Developmentally Disabled If a member has an approved HCBS waiver, the SIL budget will automatically be applied. For more information regarding the SIL, see IHCPPM 3010.20.15 and 3315.00.00.
The Eligibility System will automatically update the HCBS waiver status, workers are unable to make these updates. The waiver status is received from the approving waiver State agency. Not all HCBS waiver interfaces will form the SIL budget. The SIL budget will form in the Eligiblity System when the interface displays: • Active • Pend for Aid and Eligibility • Pend for Other Information The SIL budget will not form in the eligibility system when the interface displays: • Targeted • Terminated from Waiver • Denied
When a pregnant individual receives an increase in income, their Medicaid eligibility must continue without change.14 They shall remain eligible in the same category regardless of an income increase. If a pregnant individual is enrolled in another mandatory category (i.e., MASI) or covered under a waiver, they can remain in that category as long as they meet eligibility requirements. Pregnant Individuals who lose eligibility from a mandatory category should transition to MAMA or MAGP through the end of their post-partum period. The income that the member has when they report the pregnancy determines if the member will go into MAMA or MAGP. Once the pregnancy coverage is open the category will not change until after the post-partum period ends with the exceptions of voluntary withdrawal, death, or moved out of state. 15 Exception: If a member’s Medicaid is set to close for a reported change other than death, moving out of Indiana, or voluntary withdrawal; but before the effective date of the closure DFR discovers that the person is pregnant; eligibility should be re-evaluated for a potential rescission of the closure. Note: Effective 4/1/22, members eligible for full coverage Medicaid/CHIP while pregnant receive continuous post-partum coverage for 12 months beginning the last day of pregnancy through the end of the month in which the 12-month period ends.16
Medical coverage is available to certain parents/caretakers, infants, and children, former foster children ages 18 to 26 who were enrolled in Medicaid (any state) on their 18th birthday, and pregnant women under the Hoosier Healthwise Program. Additionally, medical coverage under the Healthy Indiana Plan (HIP) is available to adults between ages 19 and 64, effective February 1, 2015. Hoosier Healthwise is funded by Title XIX-Medicaid and by the Children’s Health Insurance Program-Title XXI and is composed of three benefit packages. Coverage under these packages is generally comprehensive, with a few exceptions, which are noted below. The packages are as follows: • Package A (Standard Plan) provides comprehensive healthcare coverage to some eligible parents and other caretaker adults, infants and children, former foster children ages 18 to 26 who were enrolled in Medicaid (any state) on their 18th birthday, and pregnant women. There are no premiums or co-payments for children under age 18. IEDSS category codes under this package are MA F, MAGP, MA X, MA Y, MA Z, MA 2, MA 9, and MA 15. • Children who are wards of the State, children in the Adoption Assistance Program, foster children and former foster children (MA 4, MA 8, MA 15) may opt out of Traditional Medicaid FFS and voluntarily enroll in Hoosier Care Connect, a coordinated care program (see 1610.00.00 for a description of the Hoosier Care Connect program). HIP is funded through a Section 1115 demonstration waiver with the CMS, Indiana’s existing cigarette tax revenues, and from a Hospital Assessment Fee. HIP coverage is available to adults aged between 19 and 64 years, who do not have Medicare, have income equal to or less than 133% of the FPL, and are not eligible for any other Medicaid category excluding low-Income parents/caretakers and transitional Medical Assistance. Under HIP, a person will qualify for either State Plan Benefits or Regular Plan Benefits. Within each plan exists Plus and Basic. Please, refer to IHCPPM 3500.00 to see the difference in benefits and cost sharing between HIP Plus and HIP Basic. To receive coverage under either HIP State Plan Plus (MASP) or HIP Regular Plan Plus (MARP), a person must make financial contributions towards a Personal Wellness and Responsibility (POWER) account that is based on their income and the FPL percentage range that the member falls in, but can be no less than $1 per month, regardless of a person’s income. To receive coverage under either HIP State Plan Basic (MASB) or HIP Regular Plan Basic (MARB), the income standard is 100% of the FPL. • HIP State Plan Plus (MASP) benefits, refer to 3520.10.00 • HIP State Plan Basic (MASB) benefits, refer to 3520.15.00 • HIP Regular Plan Plus (MARP) benefits refer to 3520.25.00. • HIP Regular Plan Basic (MARB) benefits, refer to 3520.30.00 A woman who is a member of any HIP category who becomes pregnant will be moved into the MAMA category unless income increases at the same time. If this happens, she should go into MAGP.
This category is identified in the eligibility system as MAGF. The category consists of parents and caretaker relatives of dependents less than 18 years of age and is reserved for members who do not qualify for HIP coverage due to Medicare, a waiver or refugee status. A parent includes biological, adopted, and stepparent. For the definition of a caretaker relative, please refer to IHCPPM 2420.00.00. This category also consists of low-income parent and caretaker refugees for the first twelve months after arriving in the United States. For more information regarding MAGF coverage, see IndianaMedicaid.com or refer members to call the information number on the back of their Medicaid Card.
This category is identified in IEDSS as MA F. Although MA F is considered Hoosier Healthwise, MA F is not considered a MED 3 category. Nor is it considered MED 2. Refer to IHCPPM Chapter 3800 for more specific information on MA F. Up to 12 months of full medical coverage under the Transitional Medical Assistance (TMA) category is available to parents/caretaker relatives who have been discontinued from or are denied Medicaid because of the earnings of a caretaker relative who was eligible for and received Medicaid, with the Low-Income Parent/Caretaker (LIPCT) designation, in Indiana in three of the preceding six months. TMA is also available to certain dependents. Refer to Chapter 3800. To qualify for TMA, the AG must be ineligible for Medicaid for being over 133% FPL (plus the 5% disregard) for one of the following reasons:17 • New or increased earnings of a parent or caretaker relative who is participating • member of the AG • New or increased earnings of a MA sanctioned parent or caretaker relative who is • a non-participant due to a sanction • The effective date of TMA corresponds to the date of discontinuance or the date on which the AG first becomes ineligible, whichever is earlier.18
Native Americans and Alaska Natives who qualify for HIP will automatically be placed into HIP State Plan. Additionally, Native American and Alaskan Native HIP members will not be required to make any financial contributions to a POWER Account or make any required co-pays. If a Native American and Alaska Native chooses to be covered by fee-for-service, rather than managed care, the person will then have eligibility under the MANA category.
This category is identified in IEDSS as MASP. To be eligible in this category an adult must be at least 19 years of age and less than 65 years of age and have income equal to or less than 133% of the FPL, unless the person qualifies for TMA. The upper age limit is waived for Low-Income Parent/Caretakers. A potential member may not be enrolled in or eligible for enrollment in the federal Medicare program. Eligible participants include: • Low Income parents and caretaker relatives • TMA eligible individuals; or • Individuals that qualify as medically frail.19 HIP Plus State Plan requires the participant to pay a monthly POWER Account contribution (PAC) and only has co-payments on non-emergency use of the hospital emergency department. MASP members, who are American Indian/Alaska Natives, are not required to make a financial contribution to a POWER Account.
This category is identified in IEDSS as MASB. To be eligible in this category an adult must be at least 19 years of age and less than 65 years of age (upper age limit is waived for low-income parent/caretakers). They must have income at or below 100% FPL. They will be enrolled in HIP Basic State Plan if they fail to make financial contributions toward a POWER account and fall into one of the following groups: • Low-income parents and caretaker relatives • Individuals that qualify as medically frail.20
This category is identified in IEDSS as MAPC. • To be eligible in this category an adult must have been eligible under MASP, while being determined medically frail, having income between 100% FPL and 133% FPL, and failing to make ongoing financial contributions to a POWER account. • If an MAPC member’s income decreases to below 100% FPL, they will be moved into the State Plan Basic category.
This category is identified in IEDSS as MARP. To be eligible in this category an adult must be at least 19 years of age and less than 65 years of age. A potential member may not be enrolled in or eligible for enrollment in the federal Medicare program or be eligible for any other Medicaid category.21 The income standard is 133% FPL. HIP Regular Plus requires the participant to pay a monthly POWER Account contribution (PAC) and only has co-payments on non-emergency use of the hospital emergency department.
This category is identified in IEDSS as MARB. To be eligible in this category an adult must be at least 19 years of age and less than 65 years of age with income at or below 100% FPL and will be enrolled in HIP Basic after failing to make financial contributions to a POWER account. A potential member may not be enrolled in or eligible for enrollment in the federal Medicare program or be eligible under any other Medicaid category.22 The HIP Basic benefit package applies co-payments to services. The “HIP Basic” Plan maintains essential benefits, but incorporates reduced benefit coverage, has a more limited pharmacy benefit, does not include dental, and does not include vision benefits.
This category is identified in IEDSS as MA O. To be eligible in this category a child must be under age 21, an inpatient of a Medicaid certified psychiatric facility, and meet MAGF eligibility requirements (except the age 18 limitations) as if they were living at home.23 A recipient who is approved for MA O prior to his 21st birthday remains eligible until age 22 as long as he remains in the psychiatric facility.
This category is identified in IEDSS (Indiana Eligibility Determination Services System) as MA Q (Refugee Medical Assistance (RMA) 1st 12 months for individuals entering the U.S prior to 5/5/25 or 1st 4 months for members entering the U.S on or after 5/5/25. 24 Individuals receiving or eligible to receive Refugee Cash Assistance (RCA) are eligible for Medicaid under these categories. This is the category of last resort, after all other categories have been explored. A MA Q (Refugee Medical Assistance (RMA) 1st 4-12 months (prior to 05/05/25 or 1st 4 months on or after 05/05/25) in the U.S) AG that becomes ineligible for assistance due solely to new or increased earnings may receive continued Medicaid until the end of the four/12-month period. In cases where a member of the AG obtains private medical coverage, it is imperative to answer Third Party Liability questions located in IEDSS (Indiana Eligibility Determination Services System) under Non-financial questions and properly update information on the Third-Party Liability Detail Screen. A refugee may not receive Medicaid under this provision once his initial four/twelve- month eligibility period ends. Low-income Parent/Caretaker refugees who are within their first 12 months (4-months on or after 5/5/25) of entry in the country will be placed into MAGF (Parent or Caretaker Relative, not eligible for HIP) instead of MA Q (Refugee Medical Assistance (RMA). These members will remain in MAGF up to twelve months depending on their entry date into the U.S. At the end of the eligibility period, the State Eligibility system will explore all other eligible categories for the member, including HIP.
These categories are identified in IEDSS as MAMA and MAGP. To be eligible for these categories pregnant individuals must have an attestation of pregnancy and have income less than or equal to 208% of the Federal Poverty Level, with the 5% MAGI disregard included if needed to pass.25 There are no resource eligibility requirements for these categories. If a pregnant individual receiving coverage under either of these two categories receives an increase in income which causes their countable income to exceed the standard, they remain eligible for pregnancy-related coverage through the end of the 12 months postpartum period, as explained in Section 1610.50.00.24 The 12-month postpartum period is available to an individual who meets one of the following criteria: • Applies for Medical Assistance while pregnant and is eligible on the date pregnancy ends (by birth or other means). • Applies for Medical Assistance while pregnant and is eligible on the date pregnancy ends (by birth or other means) and/or was both pregnant and financially eligible in the month of application or one of the three retro months prior to the application. • Applies for Medicaid after the child is born (or the pregnancy is terminated by other means) and was both pregnant and financially eligible in the month of application or one of the three retro months prior to the application Month. For a pregnant individual who was eligible and enrolled on the date their pregnancy ends, the agency must provide coverage described through the last day of the month in which the 12-month postpartum period ends. 25 Example 1: • Retro Month 1 – Individual was pregnant but over the income limit for MAGP • Retro Month 2 – individual was pregnant but over the income limit for MAGP • Retro Month 3 – individual was pregnant, and pregnancy ended, and they were under the income limit for MAGP Application month – individual was over the income limit for MAGP. In this case, the individual should be found eligible for retro month 3 and ongoing, as the increase in income should be disregarded until the postpartum period ends. Example 2: • Retro Month 1 – individual was pregnant but over the income limit for MAGP • Retro Month 2 – individual was pregnant but over the income limit for MAGP • Retro Month 3 – individual was pregnant, and pregnancy ended, and they were still over the income limit for MAGP • Application month – individual was under the income limit for MAGP but fails income test for all other categories In this case, the individual is not eligible for coverage, since she was not eligible for any retro month or the month that pregnancy ended, so income cannot be disregarded for their postpartum period. Example 3: • Retro Month 1 – individual was pregnant but over the income limit for MAGP • Retro Month 2 – individual was pregnant and under the income limit for MAGP • Retro Month 3 – individual was pregnant, and pregnancy ended, but they were over the income limit for MAGP • Application month – individual was over the income limit for MAGP In this case, the individual should be found eligible for Retro month 2 and ongoing, as the increase in income should be disregarded until the postpartum period ends.
This category is identified in IEDSS as MA Y. To be eligible in this category a child must be under the age of one.26 The income standard for this category is less than or equal to 208% of the Federal Poverty Level and there are no resource requirements.
This category is identified in IEDSS as MA Z. To be eligible in this category a child must be at least one year of age, but not six years old. Income standards are based on 141% of the Federal Poverty Level and there are no resource requirements.27
This category is identified in IEDSS as MA 2. To be eligible in this category a child must be at least age six (6), but under age nineteen (19).28 The income standard is based on 106% of the Federal Poverty Level and there are no resource requirements.
This category is identified in IEDSS as MA 9. This category is an eligibility expansion effective July 1, 1998. It is funded under the federal "Children's Health Insurance Program" (CHIP) enacted in the Balanced Budget Act of 1997. To be eligible in this category: • A child must be aged 1 through age 5 with income between 141% - 158% of the federal poverty level; or • Age 6 through 18 with income between 106% - 158% of the federal poverty level, and not eligible in any other Medicaid category. There are no resource requirements.
This category of Hoosier Healthwise is designated as MA 10 on IEDSS. Effective January 1, 2000, comprehensive medical coverage, under an eligibility expansion funded through the federal Children's Health Insurance Program (CHIP), is available to Indiana children under the age of 19.29 Under this category, also known as Package C, the income limit was 200% of the federal poverty guidelines at implementation and increased to 250% of the federal poverty guidelines, as of October 1, 2008. (Refer to IHCPPM Section 3010.30.00.) There are no resource requirements. Coverage is provided only to children who are ineligible for all other categories of Hoosier Healthwise. MA 10 is, therefore, last in the IEDSS Medical Hierarchy. Please note, however, that a child who fails MA 9, but who would be eligible for MA D or MA B, could receive MA 10, if otherwise eligible. (Refer to IHCPPM Section 2035.30.10). Unlike the other Hoosier Healthwise categories, MA 10 has cost-sharing requirements. There are premiums that must be paid as a condition of enrollment and ongoing eligibility, and there are co-payments for some services. Retroactive coverage is not available under this category. Coverage begins with the month of application. (Refer to IHCPPM Section 2035.60.00.)
Note: Effective 1/1/23, Former foster care children enrolled in Medicaid (any state) on their 18th birthday will transition to MA 15 (Refer to 1620.74.00 and 2035.30.25).
This category is identified in IEDSS as MA 15. To be eligible under this category, an individual must have been in foster care and enrolled in Medicaid (any state) on his/her 18th birthday and must be 18 through 26 years old.30 There are no income standards or resource requirements for this eligibility group.
This category is identified in IEDSS as MA X. MA X is based on deemed eligibility and does not have a budget or redetermination. It is a full coverage category with no cost sharing and is at the top of the Medicaid hierarchy, therefore, it should not be replaced with any other category of medical coverage. The only exception to this is if a newborn is approved for the MA D category. If an ongoing MA X child is approved for MA D, the category change will be effective the following month. A child born to an individual who was receiving (and eligible for) Traditional Medicaid, HIP, or any Hoosier Healthwise benefit package except Package C (MA 10), at the time of the child's birth, is deemed automatically eligible for Medicaid in the Newborn category. Coverage in this category continues for 12 months from birth. Refer to Sections 2225.10 and 2428.00.
This category is identified in IEDSS as MA E. Individuals may be eligible under this category when family planning services are requested. There is no age requirement. Income standards are based on 141% of the Federal Poverty Level and there are no resource requirements.
Breast and Cervical Cancer Treatment Program (ISDH): In Indiana, the Breast and Cervical Cancer Treatment program (BCCP) is administered by the State Department of Health. To be eligible, an individual must be screened and found to need treatment for breast or cervical cancer by the BCCP and have income equal to or less than 200% of the Federal Poverty Level (FPL). The Indiana Breast and Cervical Cancer Program provides access to breast and cervical cancer screenings, diagnostic testing, and treatment for underserved and underinsured women who qualify for services and meet all other Medicaid requirements. Eligibility includes: • Indiana resident • Uninsured or underinsured • Insured with unmet deductible • 30 - 49 years of age (for office visit, clinical breast exam, and Pap smear) • 50 - 64 years of age (for office visit, clinical breast exam, Pap smear, and mammogram) • 65 years of age and older if not enrolled in Medicare Part B • At or below 200% of the FPL BCCP Option 3 (MA 12): Alternatively, an individual can receive full Medicaid benefits and coverage for treatment under the BCCP Option 3 program, which is identified as the Medicaid category MA 12. To be eligible, an applicant must be diagnosed with breast or cervical cancer and referred to FSSA through ISDH, and meet the following criteria: • Indiana resident • At least 18 years old but not over 64 years old • Has income at or below 200% of the FPL • Is not eligible for Medicaid under any other category and is not enrolled in Medicare • Is uninsured or underinsured (cancer treatment not covered). The effective date of coverage is based on dates of application and diagnosis. Example 1: Application received 5/15/2020 with a diagnosis date of 4/15/2020. Effective date of coverage should be 4/1/2020. Example 2: Application received 5/15/2020 with a diagnosis date of 12/15/2019. The effective date of coverage should be 2/1/2020. (It cannot go beyond 90 days prior to application month.) For information on screening through BCCP and referrals for BCCP Option 3, see the ISDH website at: https://www.in.gov/health/cdpc/cancer/early-detection/
HCC is a managed care program for Medicaid members that are on a MED 1 category, under 60 years of age and are not: • On Medicare • In an institution • On an approved HCBS waiver HCC provides additional services including: • Medication Therapy Management • Health Care Coordination • Access to a 24-hour Nurse Helpline For HCC members that turn 60, they will be rolled into the Pathways program (see IHCPPM 1624.00.00). HCC information is not stored in the eligibility system and DFR will not have visibility to HCC assignments. If a member has a question about the HCC, they can contact their MCE (managed care entity) listed on their insurance card or by calling member services at 866-963-7383. 1623.00.00 590 PROGRAM The 590 Program provides coverage for certain healthcare services provided to Indiana Health Coverage Programs (IHCP) members ages 21 through 64 who are residents of state-owned psychiatric facilities. These facilities operate under the direction of the Indiana Family and Social Services Administration (FSSA), the Division of Mental Health and Addiction (DMHA) or the Indiana Department of Health (IDOH). Individuals who are or are incarcerated are not eligible for the 590 Program. 590 is not stored in the eligibility system, it is displayed in MMIS and is available in the Portal. If an ongoing Medicaid member is reported as residing in a SOF (State Operated Facility) and is intended to reside in the facility for 30 or more days, the facility details screen should be updated, and the case will be suspended. When the facility reports the members release from the facility, the Medicaid should be unsuspended. During the time that an individual is in the 590/SOF facility, an AR (authorized representative) form is not required for the facility to act on the members behalf. 31 Upon release from the facility, a signed AR form is required.
Indiana PathWays for Aging, also referred to as “PathWays,” is a managed care program for Medicaid members who are: • 60 years of age and older, and • Receiving Medicaid in an aged, blind or disabled category (Including MEDWorks and MASI). Members enrolled in PathWays include those who: • May or may not be enrolled in or eligible for Medicare, • May or may not be receiving LTSS (long-term support services) including those who are: • Residing in a nursing or long-term care facility, or • Receiving services under an approved PathWays waiver (formerly called the Aged and Disabled waiver). • Receiving BPHC services in a MED 1 category Medicaid members that are not eligible for PathWays include: • Those under 60 • HIP members of any age • Hoosier Healthwise Members of any age • Individuals who are only partial benefit dually eligible (QMB-only, SMLB-only, QI, or QDWI) • MAGF members who are not in the PathWays waiver • DDRS waiver recipients, including: o FSW (Family Support Waiver) o CIH (Community Integration and Habilitation Waiver) • TBI (Traumatic Brain Injury) Waiver recipients • TBI out-of-state placements • Residents of State Operated Facilities (SOF) • Program of All Inclusive Care for the Elderly (PACE) members • RCAP (Room and Board) members • Breast and Cervical cancer members on MA12 • I/DD residents in intermediate care facilities (ICF) • ESO (Emergency Services Only) members Certain populations will not be placed into the PathWays program and will remain in Fee-for- Service (FFS). These members are not required to participate in the PathWays program but have the option to Opt-in. • Individuals who are already receiving hospice upon being eligible for PathWays, • Individuals participating in self-directed Medicaid services, and • American Indians and Alaskan Natives (AI/AN). For more information refer to 2402.15.15.20. PathWays information is not stored in the eligibility system and DFR will not have visibility to PathWays assignments. If there are questions regarding the PathWays program, the member or their authorized representative can contact the MCE (managed care entity) on their insurance card. If the MCE is unable to resolve the issue/concern, then direct the member/AR to: PathWays Phone Numbers Pathways Member Support Services (MSS) Support for eligible Medicaid members, age 60 or older who are enrolled in PathWays for Aging, with navigating the various options and care transitions associated with managed care, long term care and waiver services. Pathways Member Support Services Helpline: 877-738-3511 Indiana PathWays for Aging (Enrollment Broker): Assists members with initial plan selections and plan changes, including just cause requests Indiana Pathways for Aging Indiana PathWays for Aging Helpline: 87-PATHWAY-4 (877-284-9294) 1 42 CFR 435.520 2 42 CFR 435.530 3 42 CFR 435.540 4 IC 12-10-6-1 5 IC 12-15-41; Social Security Act (SSA) 1902(a)(10)(ii)(XV); SSA 1902(a)(10)(ii)(XVI) 6 SSA 1902(a)(10)(E) 7 SSA 1905(p)(3) 8 SSA 1902(a)(10)(E) 9 42 CFR 431.625(d) 10 SSA 1902(a)(10)(E) 11 SSA 1905(p)(3)(A)(i) 12 SSA 1902(a)(10)(E) 13 SSA 1905(p)(3) 14 SSA 1902(e)(6) 15 SSA 1902(e)(16) 16 SSA 1902(e)(16) 17 405 IAC 10-4-5 18 405 IAC 10-4-1 19 405 IAC 10-4-3 20 405 IAC 10-4-3 21 405 IAC 10-4-1 22 405 IAC 10-4-1 23 42 CFR 435.222 24 45 CFR 400.211 and 90 FR 13370 25 42 CFR 435.831(1); 42 CFR 435.603 25 42 CFR §435.170 26 42 CFR 435.222 27 42 CFR 435.222 28 42 CFR 435.222 29 IC 12-17.6-3-2 30 SSA 1902(a)(10)(A)(i)(IX) 31 I.C. 29-3-3-5
Each program has separate standards established by law or regulation which must be used to determine eligibility for assistance. This chapter includes information on the following: • Resource Limits (Section 3005) • Facility Private Pay Rate (Section 3006) • Income/Need Standards (Section 3010) • MA Earned Income Disregard (Section 3035) • General Income Disregard (Section 3040) • Medicare Part D Benchmark (Section 3041) • General Earned Income Disregard (Section 3045) • Substantial Gainful Activity (Section 3046) • Minimum Earnings for MEDWorks Improved Category (Section 3047).
The resource limit is the maximum value of nonexempt resources which an assistance group (AG) may retain in order to be eligible for assistance.
The resource limit is dependent upon the category of assistance and the composition and living arrangement of the AG.1 The resource limits for Aged, Blind, and Disabled categories (MA A, MA B, and MA D) are as follows: $2000 for an applicant/member, who is single or whose spouse qualifies as a "community spouse". For those in an institution, PACE members or on an HCBS waiver, MCCA rules apply.2 Example 1: Ann is in a Medicaid Certified Facility and applying for Medicaid. Ann’s spouse John, who is living in the community, has also applied under Med 1. The resource standard for Ann would follow the resource standards under MCCA at point of initially determining eligibility. After the 90-day protective period, Ann’s resource limit would be $2000. John would also have a $2000 resource limit. $3000 for an applicant/member and their spouse (whether or not the spouse is an applicant/member) if the couple is living together or separated only for medical reasons and the spousal impoverishment provisions do not apply. Example 2: Leo and Ann have both applied for Medicaid. Leo is in a nursing facility and Ann has an approved HCBS waiver. They are both applying for Med 1. Both Leo and Ann would have a combined $3000 resource limit. Spousal Impoverishment rules apply in the below scenarios: • Spouse 1 is in a nursing home, spouse 2 is in the home and not on an HCBS waiver or a PACE member • Spouse 1 is on an HCBS waver or a PACE member, spouse 2 is in the home and not on an HCBS waiver or a PACE participant Spousal Impoverishment rules do not apply in the below scenarios: • Both spouses are in a nursing home • Both spouses are on an HCBS waiver • Both spouses are PACE participants • Spouse 1 is in a nursing home and spouse 2 is on an HCBS waiver • Spouse 1 is a PACE member and spouse 2 is on an HCBS waiver • Spouse 1 is a PACE member and spouse 2 is in a nursing home For the applicant/member who is under age 18 and living with their parents and not on an HCBS waiver, the resource limit for their parents is as follows: • $2000 for a biological or adoptive parent who is unmarried or separated from their spouse [prior to June 1, 2014, the limit is $1,500]; • $3000 for biological or adoptive parents living together, or who are separated only for medical reasons [prior to June 1, 2014, the limit is $2,250]. *For children under 18, approved for Medicaid disability and on an HCBS waiver, parent’s income and resources are exempt in the budget. See IHCPPM 3315.00.00. The resource limits for MEDWorks (MADW, MADI) are: $2000 for an applicant/member, who is single or whose spouse qualifies as a "community spouse". 3 $3,000 for an applicant/member and their spouse (whether or not the spouse is an applicant/member if the couple is living together or separated only for medical reasons and the spousal impoverishment provisions do not apply). Parental resources are exempt for applicant/member children. When an institutionalized individual has a community spouse, the community spouse resource limit is the greatest of the following amounts effective January 1, 2006 • The state standard of $32,532 effective 1/1/26; ($31,584 effective 1/1/25; $30,828 effective 01/1/24; $29,724 effective 1/1/23; $27,480 effective 01/1/22; $26,076 effective 01/1/21; $25,728 effective 1/1/20; $25,284 effective 1/1/19; $24,720 effective 1/1/18; $24,180 effective 1/1/17; $23,844 effective 1/1/15; $23,448 effective 1/1/14; $23,184 effective 1/1/13; $22,728.00 effective 1/1-12; $22,728 effective 1-1-12; $21,912 effective 1/1/09 through 12/31/11; $20,880 effective 1/1/08 through 12/31/08). • The spousal share, up to a maximum of $162,660 effective 1/1/26; ($157,920 effective 1/1/25; $154,140 effective 1/1/24; $148,620 effective 01/1/23; $137,400 effective 01/1/22; $130,380 effective 1/1/21; $128,640 effective 1/1/20; $126,420 effective 1/1/19; $123,600 effective 1/1/18; $120, 900 effectives 1/1/17; $119,220 effective 1/1/15; 117,240 effectives 1/1/14; $115,920 effective 1/1/13; $113,640 effective 1/1/12; $109,560, effective 1/1/09 through 12/31/11; $104,400 effective 1/1/08 through 12/31/08). • Any number of resources ordered by a court against the institutionalized spouse for the support of the community spouse. • The amount established by an Administrative Law Judge as the result of an appeal; • The above standards were not adjusted effective 1/1/10 through 1/1/11 as usual because the CPI did not increase.
An applicant will be ineligible for long-term care services, if the applicant’s equity interest in the real property is greater than $752,000 effective 1/1/2026. Please refer to IHCPPM- 2640.10.15.06 regarding home equity restriction and how the limit set by the Federal Government affects the member/applicant resource limit for Medicaid. • From 1/1/2024 to 12/31/2024 the limit was $713,000 • From 1/1/2023 to 12/31/2023 the limit was $688,000 • From 1/1/2022 to 12/31/2022 the limit was $636,000 • From 1/1/2021 to 12/31/2021 the limit was $603,000 • From 1/1/2020 to 12/31/2020 the limit was $595,000 • From 1/1/2019 to 12/31/2019 the limit was $585,000 • From 1/1/2018 to 12/31/2018 the limit was $572,000 • From 1/1/2017 to 12/31/2017 the limit was $560,000 • From 1/1/2016 to 12/31/2016 the limit was $552,000 • From 1/1/2015 to 12/31/2015 the limit was $552,000 • From 1/1/2014 to 12/31/2014 the limit was $543,000 • From 1/1/2013 to 12/31/2013 the limit was $536,000 • From 1/1/2012 to 12/31/2012 the limit was $525,000 • From 1/1/2011 to 12/31/2011 the limit was $506,000 • From 1/1/2009 to 12/31/2010 the limit was $500,000.
This section is applicable to MA Q (Refugee Medical Assistance) only. The resource limit is $1,000 for applicants.
There are no resource limits for any of the MED 3 categories of assistance. Any number of resources may be retained by an AG.
The resource limits for the QMB, SLMB, QDW, and QI categories are:4 $9,950 effective 1/01/26 for an applicant/member who is unmarried or not living with their spouse. $14,910 effective 1/01/26 for an applicant/member and their spouse if the couple is living together.
The average monthly private pay rate for nursing facilities in the statewide geographic region to be used in computing transfer penalties as explained in Section 2640.10.35 is $8,027. This amount is in effect for applications filed on and after July 1, 2026. For applications filed on or after: 7-1-25 through 6-30-26 $7651 7-1-24 through 6-30-25 $7635 7-1-23 through 6-30-24 $7496 7-1-22 through 6-30-23 $7167 7-1-21 through 6-30-22 $6873 7-1-20 through 6-30-21 $6681 7-1-19 through 6-30-20 $6682 7-1-18 through 6-30-19 $6527 7-1-17 through 6-30-18 $6439 7-1-16 through 6-30-17 $6078 7-1-15 through 6-30-16 $5923 7-1-14 through 6-30-15 $5733 7-1-13 through 6-30-14 $5449 7-1-12 through 6-30-13 $5353 7-1-11 through 6-30-12 $5139 7-1-10 through 6-30-11 $4826 7-1-09 through 6-30-10 $4611 7-1-08 through 6-30-09 $4456 7-1-07 through 6-30-08 $4249 7-1-06 through 6-30-07 $3960 7-1-05 through 6-30-06 $3898 7-1-04 through 6-30-05 $3817 7-1-03 through 6-30-04 $3667 7-1-02 through 6-30-03 $3,598 For applications filed 11-1-98 through 6-30-02, the amount for the appropriate geographic region below is to be used. Region I $3,405.21 Region II $3,422.07 Region III $3,267.05 COUNTY REGION COUNTY REGION ADAMS l ALLEN I BARTHOLOMEW III BENTON II BLACKFORD II BOONE II BROWN III CARROLL II CASS I CLARK III CLAY III Clinton ii CRAWFORD III DAVIESS III DEARBORN III DECATUR III DEKALB I DELAWARE II DUBOIS III ELKHART I FAYETTE II FLOYD III FOUNTAIN II FRANKLIN II FULTON I GIBSON III GRANT II GREENE III HAMILTON II HANCOCK II HARRISON III HENDRICKS II HENRY II HOWARD II HUNTINGTON I JACKSON III JASPER III JAY II JEFFERSON III JENNINGS III JOHNSON II KNOX III KOSCIUSKO I LAGRANGE I LAKE I LAPORTE I LAWRENCE III MADISON II MARION II MARSHALL I MARTIN III MIAMI I MONROE III MONTOGMERY II MORGAN III NEWTON I NOBLE I OHIO III ORANGE III OWEN III PARKE III PERRY III PIKE III PORTER I POSEY III PULASKI I PUTNAM III RANDOLPH II RIPLEY III RUSH II ST. JOSEPH I SCOTT III SHELBY II SPENCER III STARKE I STEUBEN I SULLIVAN III SWITZERLAND III TIPPECANOE II TIPTON II UNION II VANDERBURGH III
Income and Need Standards are the maximum income or expense consideration that is given to an AG in order to determine financial eligibility. For some programs, both a gross income and net income comparison are necessary. The specific income or need standards of each program are discussed in the following sections. Income and Need Standards are the maximum income or expense consideration that is given to an AG in order to determine financial eligibility. For some programs, both a gross income and net income comparison are necessary. The specific income or need standards of each program are discussed in the following sections.
The income standards used in determining eligibility for MA A, MA B, and MA D AGs are based on AG size, composition, and living arrangement. The following sections list the income standards to be utilized in a given case.
The monthly income standards listed in this section are used in the eligibility determination. These standards are effective March 1, 2026. $1330 - unmarried applicant/member of any age; or applicant/member not living with a spouse $1804- married couple, either or both of whom are applicants/members. 3010.20.05.05 ADDITIONAL ELIGIBILITY INCOME STANDARDS (MED 1) The monthly income standards listed in this section are used in the eligibility determination. These standards are effective January 1, 2026. $498: A dependent child; applicable for a child not in an MA assistance group or one who is in an MA assistance group other than MA B or MA D. $498: An essential person. $994: One parent of the child applicant/member. $1491: Two parents of the child applicant/member; and $498: Stepparent.
The policies stated in this section apply only to the MA A, MA B, and MA D and MEDWorks members residing in Medicaid certified long-term care (LTC) facilities. The purpose of post-eligibility is to determine the institutionalized applicant's/member's liability to the facility. This determination also establishes the amount of the institutionalized applicant's/member's income which is allocated to meet the needs of his community spouse and certain other family members. The following standards are used in the post-eligibility calculation: Personal needs allowance: • $525 Effective 7-1-02 ($50 effective 7-1-99) this is the minimum amount allowed for all applicants/members. If the person is receiving long term care services through a home-and-community based waiver (HCBS), the personal needs allowance is equal to the Special Income Level (SIL). Refer to 3010.20.15. • In specific situations, an additional individual amount for increased personal needs is to be deducted. Refer to Section 3455.15.10. For those on the MEDWorks program (MADW and MADI) and residing in a Medicaid certified long-term care (LTC) facility, the member will have a standard patient liability applied.6 MEDWorks members with an approved HCBS waiver will continue to pay their premium (if applicable) rather than a waiver liability. Spousal allocation7 based on: • Spousal Income Standard -- $2705 effective 7-1-26 ($2644 effective 7-1-25; $2555 effective 7-1-24; $2465 effective 7-1-23; $2289 effective 7-1-22; $2178 effective 7- 1-21; $2155 effective 7-1-20; $2114 effective 7-1-19; $2058 effective 7-1-18; $2030 effective 7-1-17 through 6-30-18; $2003 effective 7-1-16 through 06-30-17; $1992 effective 7-1-15 through 6-30-16; $1967 effective 7-1-14 through 6-30-15; 1939 effective 7-1-13 through 6-30-14; $1892 effective 7-1-12 through 6-30-13; $1839 effective 7-1-11 through 6-30-12; corrected to $1822 effective 1-1-11 through 6-30- 11); $1823 effective 7-1-09 through 12-31-10; $1751 effective 7-1-08 through 6-30- 09) • Shelter Standard - $812 effective 7-1-26 ($793 effective 7-1-25; $767 effective 7-1- 24; $740 effective 7-1-23; $687 effective 7-1-22; $653 effective 7-1-21; $647 effective 7-1-20; $634 effective 7-1-19; $617 effective 7-1-18; $609 effective 7-1-17 through 06/30/18; $601 effective 7-1-16 through 06/30/17; $597 effective 7-1-15 through 6-30-16; $590 effective 7-1-14 through 6-30-15; $582 effective 7-1-13 through 6-30-14; $568 effective 7-1-12 through 6-30-13; 552 effective 7-1-11 through 6-30-12; $547 effective 7-1-09 through 6-30-11; $526 effective 7-1-08 through 6-30-08) • Maximum Maintenance Standard – $4,067 effective 1-1-26 ($3,948 effective 1-1-25; $3,854 effective 1-1-24; $3,716 effective 1-1-23; $3,435 effective 1-1-22; $3,260 effective 1-1-21; $3,216 effective 11-20; $3,161 effective 1-1-19; $3,090 effective 1- 1-18; $3,023 effective 1-1-17; $2,981 effective 1-1-15; $2,931 effective 1-1-14: $2898 effective 1-1-13; $2841 effective 1-1-12; $2739 effective 1-1-09 through 12- 31-11; $2610 effective 1-1-08) Family allocation based on: • 1/3 of the difference between a family member’s income and $2705 effective 7-1-26 ( $2644 effective 7-1-25; $2555 effective 7-1-24; $2465 effective 7-1-23; $2289 effective 7-1-22; $2178 effective 7-1-21; $2155 effective 7-1-20; $2114 effective 7-1-19; $2058 effective 7-1-18; $2030 effective 7-1-17 through 6-30-18; $2003 effective 7-1-16 through 06-30-17; $1992 effective 7-1-15 through 06-30-16; $1967 effective 7-1-14 through 6-30-15; $1939 effective 7-1-13 through 6-30-14; $1892 effective 7-1-12 through 6-30-13; $1839 effective 07-01-11 through 6-30-12; $1822 corrected effective 01-01-11 through 06-30-11; $1823 effective 07-01-09 through 12-31-10; $1751 effective 07-07-08 through 06-30-09) 3010.20.15 SPECIAL INCOME LEVEL USED FOR INSTITUTIONAL RESIDENTS, PACE members AND WAIVER SERVICES (MED 1) The Special Income Level (SIL) used in determining eligibility for Institutional Residents, PACE members and for certain HCBS waivers is 300% of the SSI Maximum Benefit Rate. Effective 1-1- 26, the SIL is $2982 ( effective 1-1-25, the SIL is $2901; effective 1-1-24, the SIL is $2,829; effective 1-1-23, the SIL is $2,742; effective 1-1-22, the SIL is $2,523; effective 1-1-21, the SIL is $2,382; effective 1-1-20, the SIL is $2,349; effective 1-1-19, the SIL is $2,313; effective 1-1-18, the SIL is $2,250; effective 1-1-17, the SIL is $2,205; effective 1-1-15, the SIL is $2,199; effective 1-1-14, the SIL is $2,163; effective 1-1-13, $2,130; effective 1-1-12, $2,094; 1-1-09 through 12- 31-11, the SIL was $2,022). The income standard for the Behavioral and Primary Healthcare Coordination Waiver (BPHC) is 300% of the Federal Poverty Level, or $3,990 effective 3-1-26. 3010.20.20 INCOME STANDARD/PREMIUMS FOR MEDWorks The income standard for MADW and MADI is 350% of the Federal Poverty Level. Only the income of the MEDWorks member is counted in the budget. Children/parent’s income is not included, nor is income of a *spouse included when determining MEDWorks eligibility. Example 1: Kyle and Erica are married, Kyle is disabled and has earned income; Erica is also employed but is not disabled. Kyles gross monthly income (after allowable deductions) = $3500 Kyle is eligible for MEDWorks using only his income of $3500 Ericas gross monthly income = $5000 She is not applying for Medicaid Kyle is income eligible for MEDWorks, the next step is to determine his premium using their combined income: The combined income = $8500 Based on the chart below, Kyles premium payment is $187 If both spouses are on MEDWorks, then each members income counts in their individual eligibility determination only, but their combined income counts in the premium calculation. Example 2: Steve and Kathy are married, they are both disabled, and have earned income. Steves gross monthly income (after allowable deductions) = $1900 Steve is eligible for MEDWorks using only his income of $1900 Kathys gross monthly income (after allowable deductions) = $2500 Kathy is eligible for MEDWorks using only her income of $2500 Both are income eligible for MEDWorks, the next step is to determine their premium using their combined income: The combined income = $4400 Based on the chart below, their combined premium payment is $145 Effective March 1, 2026, the standard is $4,655. Premiums are listed in the following table. PREMIUMS Family Size Monthly Gross Income Premium Amount $1995 to $2328 $48 $2329 to $2660 $69 $2661 to $3325 $107 $3326 to $3990 $134 $3991 to $4655 $161 $4656 and over* $187 $2705 to $3156 $65 $3157 to $3607 $93 $3608 to $4509 $145 $4510 to $5410 $182 $5411 to $6312 $218 $6313 and over* $254 * While spousal income of a MEDWorks member is not included in the initial budget calculation, the gross income is used to calculate the amount, if any, of the premium. An amount paid for private health insurance that covers the MEDWorks member is deducted from the premium amount8.
The MED 2 income standards are based on the TANF standards. The following chart lists the monthly income standards to be used for the MA Q category of assistance.9 AG WITH A PARENT INCLUDED AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $139.50 $463.50 $229.50 $522.00 $288.00 $580.50 $346.50 $639.00 $405.00 $697.50 Each Additional Member, add $58.50 AG WITH CHILDREN ONLY AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $139.50 $432.00 $198.00 $490.50 $256.50 $549.00 $315.00 $607.50 $373.50 $666.00 Each Additional Member, add $58.50
There is no income standard for the first six months of eligibility. Beginning with the seventh month, the AG's average gross monthly earnings (minus childcare expenses) must be equal to or less than 185% of the Federal Poverty Level for TMA eligibility to continue.10 The income standards effective March 1, 2026, are shown below: TMA STANDARDS AG SIZE EARNINGS AG SIZE EARNINGS $2461.00 $5964.00 $3337.00 $6839.00 $4212.00 $7715.00 $5088.00 $8591.00 For each additional member, add $875
The income standards for the MA 2, MA Y, MA Z, MA 9, MA O, MAE, MAZ, MASB, MASP, MARB, MASB, MAGP, MA 14, and MA 10 categories of assistance are based on the Federal Poverty Guidelines. The size of the AG determines the income standard to be used. Gross income and net income may not exceed the standards in order for financial eligibility to exist. The following sections list the standards to be used in the consideration of income.
This chart lists the monthly income standards to be used for low-income parents or caretakers (MAGF), and Children Age 18 and under 22 (MA O). AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $152.00 $498.00 $247.00 $561.00 $310.00 $624.00 $373.00 $687.00 $435.00 $750.00 For each additional member, add $63.00
This chart lists the monthly income standards to be used for uninsured adults who are at least 19 years old and less than 65 years old (MASP, MARP, MANA, MAPC, and MAHL). The income standard is based on 133% of the Federal Poverty Level (FPL), effective March 1, 2026. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $1769.00 $4288.00 $2399.00 $4917.00 $3028.00 $5547.00 $3658.00 $6176.00 For each additional member, add $630.00 This chart lists the monthly income standards to be used for uninsured adults who are at least 19 years old and less than 65 years old (MASB and MARB) who fail to make required financial contribution to a POWER Account and are eligible for HIP Basic coverage. MASB for Transitional Medical Assistance (TMA) members are exempt from this chart. The income standard is based on 100% of the FPL, effective March 1, 2026. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $1330.00 $3224.00 $1804.00 $3697.00 $2277.00 $4170.00 $2750.00 $4644.00 3010.30.10.05 INCOME STANDARDS LOW-INCOME PARENT CARETAKER This chart lists the monthly income standards to be used for Low-Income Parent Caretakers aged between 19 and 64 (MASP and MASB) and for low-income parent caretakers who are eligible for Medicare or eligible to receive an HCBS Waiver (MAGF). Low Income Parent Caretakers refugees who are within their first 12 months in the country will be placed into MAGF instead of MA Q. These members will be able to remain in MAGF for 12 months. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $152.00 $435.00 $247.00 $498.00 $310.00 $561.00 $373.00 $624.00 For each additional member, add $63.00 3010.30.10.10 INCOME STANDARDS HIP TMA For HIP TMA adults aged at least 19 years old and less than 65 years old (MASP and MASB), refer to 3010.26.00.
This chart lists the monthly income standards to be used for children 6 years old and through the age of 18 (MA 2) effective March 1, 2026. Financial eligibility exists if net income is less than or equal to the standards per AG size.11 The income standard is based on 106% of the Federal Poverty Level. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $1410.00 $3417.00 $1912.00 $3919.00 $2414.00 $4421.00 $2915.00 $4922.00 For each additional member, add $502.00
This chart lists the monthly income standards for the following groups: children age 1 through 5 (MA Z) and family planning services (MA E), effective March 1, 2026.12 The income standard is based on 141% of Federal Poverty Level. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $1876.00 $4545.00 $2543.00 $5213.00 $3211.00 $5880.00 $3878.00 $6548.00 For each additional member, add $667.00
This chart lists the monthly income standards to be used for the following groups: children age 1- 5, 141-158% FPL; children age 6-18, 106-158% FPL. The category is MA 9. The standards are effective March 1, 202613 (Refer to Section 1620.86 for an explanation of this category). The income standard is based on 158% of Federal Poverty Level. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $2102.00 $5093.00 $2850.00 $5841.00 $3598.00 $6589.00 $4345.00 $7337.00 For each additional member, add $748.00
This chart lists the monthly income standards for pregnant women (MAGP) and infants under age one (MA Y). These standards are based on 208% of the Federal Poverty Level and are effective March 1, 2026. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $ 2767.00 $ 6705.00 $ 3751.00 $ 7690.00 $ 4736.00 $ 8674.00 $ 5720.00 $ 9659.00 For each additional member, add $984.00
Note: Effective 1/1/23, Former foster care children enrolled in Medicaid (any state) on their 18th birthday will transition to MA 15 (Refer to 1620.74.00 and 2035.30.25).
This chart lists the income standards for children from birth through 18 years of age (MA 10), which is Package C, Children's Health Plan. The standard is based on 250% of the Federal Poverty Level (FPL) and effective March 1, 2026 For children with income above 158% FPL standard and below the 250% FPL standard, there are tiers to determine the premium amount, which will also consider the number of children covered. AG SIZE MONTHLY LIMIT TIER 1 (175% FPL) MONTHLY LIMIT TIER 2 (200% FPL) $2328.00 $2660.00 $3156.00 $3607.00 $3985.00 $4554.00 $4813.00 $5500.00 $5641.00 $6447.00 $6470.00 $7394.00 NUMBER OF CHILDREN MONTHLY PREMIUMS TIER 1 TIER 2 $22.00 $33.00 2 or more $33.00 $50.00 AG SIZE MONTHLY LIMIT TIER 3 (225% FPL) MONTHLY LIMIT TIER 4 (250% FPL) $2993.00 $3325.00 $4058.00 $4509.00 $5123.00 $5692.00 $6188.00 $6875.00 $7253.00 $8059.00 $8318.00 $9242.00 NUMBER OF CHILDREN MONTHLY PREMIUMS TIER 3 TIER 4 $42.00 $53.00 2 or more $53.00 $70.00
Income standards for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Disabled Worker (QDW), and Qualified Individual (QI) are based on the Federal Poverty Income Guidelines. The size of the AG determines the income standard to be used. If countable income exceeds the standard, the applicant/ member is not financially eligible.14
This chart lists the monthly income standards to be used for the QMB (MA L) category of assistance effective March 1, 2026. This standard is based on 150% of the Federal Poverty Income Guidelines. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $1995.00 $4835.00 $2705.00 $5545.00 $3415.00 $6255.00 $4125.00 $6965.00 For each additional member, add $710.00
This chart lists the monthly income standards to be used for the SLMB category of assistance effective March 1, 2026. This standard is based on 170% of the Federal Poverty Income Guidelines. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $2261.00 $5480.00 $3066.00 $6285.00 $3871.00 $7089.00 $4675.00 $7894.00 For each additional member, add $805.00
This chart lists the monthly income standards to be used for the QDW (MA G) category of assistance effective March 1, 2026. This standard is based on 200% of the Federal Poverty Income Guidelines. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $2660.00 $6447.00 $3607.00 $7394.00 $4554.00 $8340.00 $5500.00 $9287.00 For each additional member, add $947.00
This chart lists the monthly income standards to be used for the QI (MA I) effective March 1, 2026. This standard is based on 185% of the Federal Poverty Levels. AG SIZE NET INCOME STANDARD AG SIZE NET INCOME STANDARD $2461.00 $5964.00 $3337.00 $6839.00 $4212.00 $7715.00 $5088.00 $8591.00 For each additional member, add $875.00
The general income disregard for these categories increased to $20.00.
The Medicare Part D Benchmark effective 01-01-26 is $38.44 (01-01-2025 was $49.58). Medicare members with income of less than 150% of the FPL receive a full subsidy for purchasing Part D prescription coverage, regardless of Medicaid status. The amount of the subsidy is what is referred to as the “benchmark;” this amount may periodically change. The members may choose a more expensive policy and pay the difference. This additional expense is all that should be credited to their budget. Medicare members who are over 150% of the FPL will only qualify for the subsidy after they are approved for full coverage Medicaid if they are in an institution, PACE members or on an HCBS approved waiver. Months before Medicaid eligibility is established may be credited with the entire amount the applicant is paying for Part D coverage, if acceptably verified. The Part D Benchmark should be deducted for all months after Medicaid is approved. This means only the amount over the benchmark should be credited as an ongoing medical expense. After the LIS (Low-Income Subsidy) has started, if the member receives bills from the Medicare part D plan, they chose with their health insurance company, the full amount should be entered on the medical expense screen, as this is what the member is responsible for. Example 1: Logan is an applicant and is a Medicare member applying for full coverage Medicaid with income under 150% FPL. Logan chooses a Medicare Part D plan that costs $65.00 per month. Due to Logan choosing a plan that is over the benchmark amount, he would only get credit for the difference on the medical expense screen. Logan would get credit for $65.00- $49.58 (benchmark) = $15.42 as a monthly expense on the medical expense screen. Example 2: Eric is over 150% FPL and is applying for Medicaid; he is a Medicare member and has Part D coverage. The Medicare Part D plan that Eric chose costs $75.00 per month. For retroactive and application months, enter the full amount of the Medicare Part D premium as a medical expense. If Medicaid passes for all months, before authorizing eligibility, the worker should return to the medical expense screen and update the most recent month reflect the deduction of the current benchmark amount. Eric’s application was approved in July. The Medical Expenses screen should budget the Part D premiums as: April: $75.00 May: $75.00 June: $75.00 July: $75.00 August: $25.42 ($75.00 – 49.58 benchmark)
In the eligibility determination, $20 per month of income is disregarded. The income disregard is applied once to the AG's combined total income.15
Substantial Gainful Activity (SGA) is the limitation on gross earnings that is used to determine categorical eligibility. The amount is $ 1,690 effective January 1, 2026 (effective 1-1-25, $1,620; effective 1-1-24, $1,550; effective 1-1-23, $1,470; effective 1-1-22, $1,350, effective 1-1-21, $1,310; effective 1-1-20, $1,260; effective 1-1-19, $1,220; effective 1-1-18, $1,180; effective 1-1- 17, $1,170; effective 1-1-16, $1,130; 1-1-15, $1,090; 1-1-14, $1,070; $1,040 effective 1-1-13, $1,040; 1-1-12, $1,010; 1-1-10 through 12-31-11 was $1,000; effective 1-1-09, $980; effective 1- 1-08, $940). 3047.00.00 MINIMUM EARNINGS FOR MEDWorks IMPROVED CATEGORY (MED 1) The monthly minimum earnings amount for MADI is $290. This is calculated by multiplying the federal minimum wage, currently as of July 24, 2009, $7.25 times 40.16 1 SSA 1905(p)(1)(C) 2 42 U.S.C. 1396R-5 3 42 U.S.C. 1396R-5 4 Sec. 1860D-14 [42 U.S.C. 1395w-114] (a) (3)(D) 5 IC 12-15-7-2; 405 IAC 2-3-17 6 405 IAC 2-9-3 7 405 IAC 2-3-17; SSA 1924(d) 8 Indiana State Plan Attachment 2.6-A 9 45 CFR 233.20(a)(2) 10 SSA 1925 11 IC 12-15-2-1; IC 12-15-2-11 12 IC 12-15-2-12; 42 U.S.C. 1396d(n)(2) 13 IC 12-15-2-14 14 IC 12-15-2-26 15 405 IAC 2-9-2(d) 16 405 IAC 2-9-5(b)