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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MAABD MEDICAL GROUPS (Cont’d.) Were receiving SSI benefits; Lost SSI due to receipt of Title WS1 Widow/Widowers and II spousal benefits; WS3 WS9 Surviving Divorced Spouses Public Law Resource Limit $2,000 Not entitled to Medicare Part A. SDX will display “S” in Public Law column. SU1 SU3 SU9 Suspension of SSI due to Income Public Law Resource Limit $2,000 Social Security determines this status. SDX will display “I” in the Public Law column. SS1 SS3 SS9 SSI Institutional $30 SSI Institutional payment rate Categorically eligible, income and resource determination made by SSA. Residing in long term care. Over 65 years of age, blind or disabled; SI1 SI3 SI9 State Institutional special income group Income between SSI payment level and 142% of SSI payment; Resource limit $2,000 In-patient stay greater than 30 days; Requires spousal resource assessment; Patient liability determination post eligibility. WB1 WB3 WB9 Would be receiving SSI or State Supplement if not in LTC Income > 30 but < SSI; Resource limit $2,000 Over 65 years of age, blind or disabled. Over 65 years of age, blind or disabled; In-patient stay greater than 30 CM1 Income $1,339.40 days; CM3 County Match Institutional 300% SSI payment level; CM9 Resource limit $2,000 Requires spousal resource assessment; Patient liability determination post eligibility. APPENDIX A INCOME RESOURCE CHARTS Division of Social Services Medical Assistance Manual 25 July MTL 06/25 MAABD MEDICAL GROUPS (CONT’D)