What Is Medicaid?

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Medicaid is a partnership between the Federal Government and the various States intended to provide health insurance coverage for the poor and chronically disabled. It is funded by both partners and is administered by the individual States.

There are many categories of Medicaid and the benefits of each vary by category. The categories are determined by the Medicaid Recipient’s annual income in relation to the Federal Poverty Level (FPL) and the Medicaid Recipient’s Resources in relation to the limit for Supplemental Security Income, or SSI, eligibility. The FPL is determined by income and family size. The SSI limit varies by County and is determined by and available from Medicaid by dialing 211 on your touch-tone phone.

The chart below shows the various FPL’s for Calendar Year 2016 and how they vary with both income and family size. For example, the Federal Poverty Level for a couple with no children is $16,020.

Family  Percentage of the Federal Poverty Level (FPL) 

 Household Size

 100%

 133%

 150%

200%

250%

 300%

400%

 1

$11,880

$15,800

$17,820

$23,760

$29,700

$35,640

$47,520

 2

16,020

 21,307

24,030

  32,040

40,050

48,060

64,080

 3

20,160

 26,813

30,240

  40,320

50,400

60,480

80,640

 4

24,300

 32,319

36,450

  48,600

60,750

72,900

97,200

 5

28,440

 37,825

42,660

  56,880

71,100

85,320

113,760

 6

32,580

 43,331

48,870

  65,160

81,450

97,740

130,320

 7

36,730

 48,851

55,095

  73,460

91,825

110,190

146,920

 8

40,890

 54,384

61,335

  81,780

102,225

122,670

163,560

 

QMB – Qualified Medicare Beneficiary without other Medicaid EligibilityThe following is a brief description of each of the various Medicaid Eligibility Categories:

An individual entitled to Medicare Part A with an income of 100% of the Federal Poverty Level (FPL) or less and resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility and is not otherwise eligible for full Medicaid Benefits through the State. Medicaid pays their Medicare Part A premium, if any, Medicare Part B Premium, and Medicare deductibles and Coinsurance for Medicare services provided by Medicare providers to the extent consistent with the Medicaid State Plan.

QMB+

An individual who meets the standards for QMB eligibility, and who also meets the criteria for full Medicaid benefits. Medicaid pays their Medicare Part A premium, if any, Medicare Part B Premium, and Medicare deductibles and Coinsurance for Medicare services provided by Medicare providers to the extent consistent with the Medicaid State Plan. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or by spending down excess income to the Medically Needy level.

SLMB – Specified Low Income Medicare Beneficiary without other Medicaid

An individual entitled to Medicare Part A, with an income that exceeds 100% of the FPL but less than 120% of the FPL with resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility and who is not otherwise eligible for Medicaid. These individuals are eligible for Medicaid payment of the Medicare Part B premium only. They do not qualify for any additional Medicaid benefits.

SLMB+

An individual who meets the standards for SLMB eligibility and who also meets the criteria for full State Medicaid benefits. These individuals are entitled to Medicaid payment of the Medicare Part B premium, in addition to full State Medicaid benefits. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or by spending down excess income to the Medically Needy level.

QI – Qualifying Individual

An individual entitled to Medicare Part A, with an income of at least 120% of the FPL but less than 135% of the FPL with resources that do not exceed twice the limit for Supplemental Security Income (SSI) eligibility and who is not otherwise eligible for Medicaid. This individual is eligible for Medicaid payment of the Medicare Part B premium.

QDWI – Qualified Disabled and Working Individual

An individual who has lost Medicare Part A benefits due to a return to work but is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% of the FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. These individuals are eligible for Medicaid payment of the Medicare Part A premium only.

FBDE – Other Full Benefit Dual Eligible

An individual who does not meet the income or resource criteria for QMB or SLMB, but is eligible for Medicaid either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home or community-based waivers.

These are just generalized descriptions of these categories. If you believe you may fall into one of these categories, dial 211 on your touch-tone phone and get connected with Medicaid directly for further information and evaluation of your eligibility.