Medicare-Medicaid Pay-Down of Assets
State law and regulations impose income and asset limits on persons applying for Medicaid.
The income limit for the institutional Medicaid program and certain home and community-based waiver programs is determined by the Ohio Department of Medicaid. To qualify for Medicaid through SSI the income limit for an aged, blind or disabled individual cannot exceed $967 per month or $1,450 for a couple.
“Spenddown amount” means the dollar amount by which the individual’s countable income exceeds the applicable Medicaid need standard. The individual must satisfy the spenddown amount to become eligible for Medicaid for all or part of a given month. If the individual’s countable monthly income exceeds the applicable Medicaid need standard, the administrative agency must calculate the amount, if any, of the monthly spenddown as follows:
(1) Medical insurance premiums.
(a) Determine the total amount of all monthly medical insurance premiums of the individual and family members. Do not round down. Subtract that amount from the individual’s countable monthly income and round down to the nearest whole dollar.
(i) If the result is less than or equal to the applicable Medicaid need standard, the individual is eligible for Medicaid for the entire month without any monthly spenddown amount.
(ii) If the result is greater than the applicable Medicaid need standard, continue to paragraph (C)(2) of this rule.
(b) An individual who is eligible for a Medicare premium assistance program (MPAP) in accordance with rule 5160:1-3-02.1 of the Administrative Code has the option to decline such eligibility.
(i) If the individual accepts MPAP eligibility and the administrative agency has obtained verification that the Medicaid program has begun paying the individual’s Medicare premiums, then the individual’s Medicare premiums are not deducted in the spenddown process.
(ii) If the individual declines MPAP eligibility, then the individual’s Medicare premiums, if paid, are deducted at the step set forth in paragraph (D)(1)(a) of this rule.
(2) Determine the total NF or ICF-IID cost of care for the individual as calculated in accordance with paragraph (F)(3) of this rule. Do not round down. Subtract that amount from the result calculated in paragraph (D)(1)(a) of this rule and round down to the nearest whole dollar.
(a) If the result is less than or equal to the applicable Medicaid need standard, the individual is eligible for Medicaid for the entire month without any monthly spenddown amount.
(b) If the result is greater than the applicable Medicaid need standard, continue to paragraph (D)(3) of this rule.
(3) Determine the total amount of the individual’s and family members’ UPMEs as determined in accordance with paragraph (F)(2) of this rule. Do not round down. Subtract that amount from the result calculated in paragraph (D)(2) of this rule and round down to the nearest whole dollar.
(a) If the result is less than or equal to the applicable Medicaid need standard, the individual is eligible for Medicaid for the entire month without any monthly spenddown amount.
(b) If the result is greater than the applicable Medicaid need standard, the amount that is over the need standard is the individual’s monthly spenddown amount. In order to become eligible for Medicaid for all or part of the month, the individual must satisfy the monthly spenddown amount through one of the methods set forth in paragraph (E) of this rule.
Medicaid Standards Help Sheet
Ohio Admin. Code 5160:1-3-.02.3
5160:1-3-.04.1