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Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015

Introduction
  1. Julia Paradise, Barbara Lyons, and Diane Rowland, “Medicaid at 50,” Kaiser Family Foundation (May 2015), available at http://kff.org/medicaid/report/medicaid-at-50/. The total number of Medicaid beneficiaries with disabilities is higher because people with disabilities can qualify for Medicaid through a poverty-related pathway based solely on their low income status; in this case, their disability status would not necessarily be recorded. This report focuses on disability-related pathways to Medicaid eligibility.

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  2. Juliette Cubanski, Giselle Casillas, and Anthony Damico, “Poverty Among Seniors: An Updated Analysis of National and State Level Poverty Rates Under the Official and Supplemental Poverty Measures,” Kaiser Family Foundation (June 2015) (finding that 33% of seniors had incomes below 200% of the official poverty measure, while 45% of seniors had incomes below twice the poverty threshold under the Supplemental Poverty Measure in 2013), available at http://kff.org/medicare/issue-brief/poverty-among-seniors-an-updated-analysis-of-national-and-state-level-poverty-rates-under-the-official-and-supplemental-poverty-measures/.

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  3. Erica Reaves and MaryBeth Musumeci, “Medicaid and Long-Term Services and Supports: A Primer,” Kaiser Family Foundation (Dec. 2015), available at http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/.

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  4. For information about Medicaid eligibility through poverty-related pathways, see Kaiser Family Foundation, “Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey” (Jan. 2016), available at http://kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/.

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  5. Katie Beckett survey data were supplemented with information about states’ HCBS waivers targeted to comparable populations available on CMS Medicaid.gov, https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/waivers_faceted.html.

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Report
  1. 42 U.S.C. § 1396a(a)(10)(A)(i)(II); but see 42 U.S.C. § 1396a(f).

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  2. The SSI federal benefit rate is unchanged for 2016. Social Security Administration, “SSI Federal Payment Amounts for 2016,” available at https://www.ssa.gov/oact/cola/SSI.html.

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  3. 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 report).  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).

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  4. Dual eligible beneficiaries qualify for both Medicare and Medicaid. All dual eligible beneficiaries qualify for Medicaid assistance with their Medicare out-of-pocket costs through one of the MSPs described in this section. Additionally, Medicare beneficiaries who qualify for Medicaid through another (independent) poverty or disability-related eligibility pathway also receive full Medicaid benefits. These “full duals” receive Medicaid services that Medicare does not cover, such as long-term care, eyeglasses or hearing aids. Medicare beneficiaries who qualify only for an MSP are known as “partial duals” and receive Medicaid help only with Medicare premiums and/or cost-sharing. See generally Katherine Young et al. “Medicaid’s Role for Dual Eligible Beneficiaries” Kaiser Family Foundation (Aug. 2013), available at http://kff.org/medicaid/issue-brief/medicaids-role-for-dual-eligible-beneficiaries/.

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  5. Medicare Part D, which covers prescription drugs, has financial assistance for low-income beneficiaries (the Low Income Subsidy program) built into the program instead of being available through Medicaid. See generally Kaiser Family Foundation, “The Medicare Part D Prescription Drug Benefit” (Oct. 2015), available at http://kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/.

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  6. Medicare Part A also requires co-insurance for hospital stays over 60 days. Most Medicare beneficiaries qualify for Part A without a premium. Juliette Cubanski et al., “A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers”, Kaiser Family Foundation (March 2015), available at http://kff.org/medicare/report/a-primer-on-medicare-key-facts-about-the-medicare-program-and-the-people-it-covers/.

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  7. Ibid.

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  8. The President’s FY 2017 budget proposes to streamline enrollment for the Medicare Savings Programs by setting a national standard for income and asset definitions. Office of Management and Budget, “Budget of the U.S. Government” at 61, available at https://www.whitehouse.gov/sites/default/files/omb/budget/fy2017/assets/budget.pdf.

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  9. 42 U.S.C. § 1396d(p).

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  10. 42 U.S.C. § 1396a(a)(10)(E)(iii).

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  11. 42 U.S.C. § 1396a(a)(10)(E)(iv).

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  12. Maine also disregards $75 of income in addition to other income disregards for MSP eligibility. Consumers for Affordable Health Care and Maine Equal Justice Partners, “MaineCare Eligibility Guide” (June 10, 2015), available at http://www.mejp.org/sites/default/files/MaineCare-Eligibility-Guide-June-2015.pdf.

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  13. 42 U.S.C. § § 1396a(a)(1o)(A)(ii)(X); 1396a(m).

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  14. 42 U.S.C. § § 1396a(a)(10)(C); 1396d(a)(iii), (iv) and (v).

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  15. Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY 2011 MSIS.  Because 2011 data were unavailable, 2010 data were used for Florida, Kansas, Maine, Maryland, Montana, New Mexico, New Jersey, Oklahoma, Texas, and Utah.

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  16. States’ medically needy income levels are low because they were tied to the Aid to Families with Dependent Children (AFDC) payment levels that were in place in 1996. Specifically, federal rules require medically needy income levels to be no higher than 133 1/3% of the state’s maximum AFDC level for a family of two without income or assets as of July 16, 1996. States can raise their medically needy income levels if they increase their TANF income standards, but relatively few states do so (TANF replaced AFDC in 1996). 42 U.S.C. § § 1396b(f)(1)(B)(i); 1396u-1(b) and (f)(3).

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  17. For more information on the medically needy program and how to calculate spend down, see Molly O’Malley Watts and Katherine Young, “The Medically Needy Program: Spending and Enrollment Update,” Kaiser Family Foundation, (Dec. 2012), available at http://kff.org/medicaid/issue-brief/the-medicaid-medically-needy-program-spending-and/.

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  18. 42 U.S.C. § 1396a(e)(3); 42 C.F.R. § 435.225.

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  19. 42 U.S.C. § § 1396a(a)(10)(A)(ii)(XIX); 1396a(cc)(1).

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  20. 42 U.S.C. § 1396a(a)(1o)(A)(ii)(XV) and (XVI); § 1396o(g).

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  21. Center for Medicaid and CHIP Services, “Employment Initiatives,” accessed Sept. 16, 2015, available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-Programs/Employment-Initiatives.html.

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  22. Those in institutions must have resided there for at least 30 days. 42 U.S.C. § 1396a(a)(10)(ii)(V) and (VI).

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  23. Most states use Section 1915(c) waivers to offer HCBS. Nearly 1.5 million people in 48 states (including DC) received Medicaid HCBS through these waivers in 2012. Three other states (AZ, RI, VT) offered all home and community-based waiver services through Section 1115 demonstrations in 2012. Terence Ng, Charlene Harrington, MaryBeth Musumeci, and Erica Reaves, “Medicaid Home and Community-Based Services Programs: 2012 Data Update,” Kaiser Family Foundation (Nov. 2015), available at http://kff.org/medicaid/report/medicaid-home-and-community-based-services-programs-2012-data-update/.

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  24. 42 U.S.C. § 1396a(q).

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  25. 42 C.F.R. § 435.726. States use different methodologies to determine the monthly personal needs allowances for HCBS beneficiaries. For example, Maryland allows individuals to deduct housing costs from income. Most states allow individuals to deduct their uncovered medical bills from income.

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  26. In addition, NJ’s personal needs allowance for HCBS beneficiaries is $109 per month for alternative living facilities and $2,199 per month for other HCBS.

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  27. See generally 42 U.S.C. § 1396r-5(d).

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  28. Section 2404 of the ACA makes spousal impoverishment protections for most HCBS waiver beneficiaries (at 42 U.S.C. § 1396r-5(h)(1)(A)) mandatory from Jan. 2014 through Dec. 2018.

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  29. California regulations to apply the $828,000 limit have not yet been adopted.

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  30. This option only applies to states that elect the special income rule but do not offer nursing facility services to medically needy groups. 42 U.S.C. § 1396p(d)(4)(B).

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  31. Not all states’ survey responses and § 1915(i) state plan amendments specify whether the state is using this option to cover individuals not otherwise eligible for Medicaid.

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  32. Prior to the ACA, Section 1915(i) authorized states to offer HCBS through a state plan amendment “for individuals eligible for medical assistance under the State plan whose income does not exceed 150 percent of the poverty line” and who meet needs-based criteria for HCBS. Thus, to qualify for Section 1915(i) HCBS, individuals had to meet the Section 1915(i) financial and functional eligibility criteria and be eligible for Medicaid through an existing Medicaid state plan pathway. The ACA amended Section 1915(i) by creating a new Medicaid coverage group which, at state option, provides an independent pathway to Medicaid eligibility (including state plan benefits and HCBS) for those not otherwise eligible for Medicaid under another pathway. 42 U.S.C. § 1396a(a)(10)(A)(ii)(XXII) (authorizing state plan option to make categorically needy medical assistance available to individuals “who are eligible for home and community-based services under needs-based criteria established under [Section 1915(i)(1)(A) or (6)], and who will receive home and community-based services pursuant to a State plan amendment under such subsection.”).

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  33. MaryBeth Musumeci, “A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion,” Kaiser Family Foundation (Aug. 2012), available at http://kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/.

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  34. Kaiser Family Foundation, State Health Facts, “Status of State Action on the Medicaid Expansion Decision” (Feb. 24, 2016), http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

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  35. MaryBeth Musumeci, “The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities,” Kaiser Family Foundation (April 2014), available at http://kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  36. Kaiser Family Foundation, “Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey” (Jan. 2016), available at http://kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/.

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  37. 42 C.F.R. § 435.911(c)(2); see also MaryBeth Musumeci, “The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities,” Kaiser Family Foundation (April 2014), available at http://kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  38. MaryBeth Musumeci, “The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities,” Kaiser Family Foundation (April 2014), available at http://kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  39. Tricia Brooks, Sean Miskell, Samantha Artiga, Elizabeth Cornachione, and Alexandra Gates, “Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey,” Kaiser Family Foundation (Jan. 2016), available at http://kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2016-findings-from-a-50-state-survey/.

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  40. 42 C.F.R. § 435.916(b); see also MaryBeth Musumeci, “The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities,” Kaiser Family Foundation (April 2014), available at http://kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/.

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  41. 42 C.F.R. § 435.916(a)(3).

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  42. Vernon Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz, and Laura Snyder, “Medicaid in an Era of Health and Delivery System Reform: Results form a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015,” at 9, Kaiser Family Foundation (Oct. 2014), available at http://kff.org/medicaid/report/medicaid-budget-survey-archives/.

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  43. Ibid.

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  44. See, e.g., MaryBeth Musumeci, Julia Paradise, Erica Reaves, and Henry Claypool, “Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace,” Kaiser Family Foundation (Oct. 2014), available at http://kff.org/medicaid/issue-brief/benefits-and-cost-sharing-for-working-people-with-disabilities-in-medicaid-and-the-marketplace/; see also National Council on Disability, “Implementing the Affordable Care Act: A Roadmap for People with Disabilities” at 39 (Jan. 19, 2016), available at https://www.ncd.gov/newsroom/2016/report-release-implementing-affordable-care-act-roadmap-people-disabilities.

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