3010.20.10 POST-ELIGIBILITY STANDARDS (MED 1)

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.