2016 Medicare – Medicaid Dual Eligible Income Levels

2016 Dual Eligible Medicare – Medicaid Charts

Centers for Medicare & Medicaid Services (CMS) released an Informational Bulletin updating the poverty guidelines that are applied to eligibility criteria for programs such as Medicaid and the Children’s Health Insurance Program (CHIP). Included with this informational bulletin is the 2016 Dual Eligible Standards chart that displays the new standards for the Medicare Savings Program categories. These standards are also available on Medicaid.gov at https://www.medicaid.gov/medicaid-chip-program-information/by-population/medicare-medicaid-enrollees-dual-eligibles/seniors-and-medicare-and-medicaid-enrollees.html.

The Informational Bulletin is available on Medicaid.gov at https://www.medicaid.gov/federal-policy-guidance/federal-policy-guidance.html.

Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid (e.g. MSPs, QMBs, SLBs, and QIs). Medicaid also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.

2016 Federal Poverty Level Standards Informational Bulletin

The 2016 guidelines reflect a 0.1 percent price increase between calendar years 2014 and 2015. After this inflation adjustment, the guidelines are rounded and adjusted to standardize the differences between family and household sizes. In rare circumstances, the rounding and standardizing adjustments in the formula result in reductions to the guidelines from the previous year for some household sizes even when the inflation factor is not negative. In order to prevent a reduction in the guidelines in these rare circumstances, beginning this year, in cases where the year-to-year change in inflation is not negative but the rounding and standardizing adjustments in the formula result in reductions to the guidelines from the previous year for some household sizes, the guidelines for the affected household sizes are fixed at the prior year’s guidelines. For 2016, the guidelines for a household size of seven or greater will remain fixed at 2015’s guidelines for all states and the District of Columbia.

For a family or household of 4 persons living in one of the 48 contiguous states or the District of Columbia, the poverty guideline for 2016 is $24,300. Separate poverty guideline figures are developed for Alaska and Hawaii, and different guidelines may apply to the Territories. The guidelines can be found at https://www.federalregister.gov/articles/2016/01/25/2016-01450/annual-update-of-the-hhs-poverty-guidelines.

To determine eligibility for Medicaid, CHIP, and advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR) for the purchase of health coverage through the Marketplace, states and the federal government generally use a percentage multiple of the guidelines (for example, 133 percent or 185 percent of the guidelines). The Federally-facilitated Marketplace (FFM) will begin using the 2016 FPLs for Medicaid and CHIP eligibility on March 4, 2016. In accordance with section 36B of the Internal Revenue Code, eligibility for APTC and CSR will continue to be determined using 2015 FPLs for all APTC and CSR for enrollment that is effective in 2016.

Included with this informational bulletin is the 2016 Dual Eligible Standards chart that displays the new standards for the Medicare Savings Program categories. These standards are also available on Medicaid.gov at https://www.medicaid.gov/medicaid-chip-program-information/by-population/medicare-medicaid-enrollees-dual-eligibles/seniors-and-medicare-and-medicaid-enrollees.html.