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Income and Resource Limits for New York State Public Health Insurance Programs

Views: 106656
Posted: 15 Jan, 2009
by David Silva (New York Legal Assistance Group)
Updated: 22 Jul, 2014
by Valerie Bogart (New York Legal Assistance Group)

The Affordable Care Act  changes the rules for Medicaid income eligibility for many BUT NOT ALL New Yorkers, expanding eligibility for many people who were not eligible before, and allowing others to be eligible for Medicaid without a "spend-down."    

 New York City Human Resources Administration  updated its Medicaid Levels Chart in June 2014 showing income and resource limits for Medicaid and other public health insurance programs in New York State, including the Medicare Savings Program.  It now shows MAGI and NON-MAGI income limits. 

This short summary chart shows that income limits have increased for the new "MAGI"  category created by the Affordable Care Act, but not for the "Non-MAGI" population - the Disabled, Aged 65+ and Blind (DAB).

2014

Non-MAGI

Disabled, 65+ or  Blind  ("DAB" or SSI-Related) and have Medicare

MAGI
(< 65, Does not have Medicare)
138% FPL***
     1 2 1 2 3
Income $809 $1,192 $1,343 $1,809 $2,276
Resources $14,550 $21,550 NO LIMIT**

NOTE:   MAGI INCOME LEVEL of 138% FPL applies to most adults who are not disabled and who do not have Medicare.  Certain populations have an even higher income limit -

  • 224% FPL for pregnant women and babies < age 1,
  • 154% FPL for children age 1 - 5. 

CAUTION:  What is counted as income may not be what you think.  For the NON-MAGI Disabled/Aged 65+/Blind, income will still be determined by the same rules as before, explained in this outline  and these charts on income disregards.    However, for the MAGI population  - which is virtually everyone under age 65 who is not on Medicare - their income will now be determined under new rules, based on federal income tax concepts - called "Modifed Adjusted Gross Income" (MAGI).   There are good changes and bad changes.  GOOD:  Veteran's benefits, Workers compensation, and gifts from family or others no longer count as income.  BAD:  There is no more "spousal" or parental refusal for this population (but there still is for the Disabled/Aged/Blind.) and some other rules.  For all of the rules see:

HOW TO DETERMINE SIZE OF HOUSEHOLD TO IDENTIFY WHICH INCOME LIMIT APPLIES

The income limits increase with the "household size."  In other words, the income limit for a family of 5 may be higher than the income limit for a single person.  HOWEVER, Medicaid rules about how to calculate the household size are not intuitive or even logical.  There are different rules depending on the "category" of the person seeking Medicaid.     Here are the 2 basic categories and the rules for calculating their household size. 

  1. People who are Disabled, Aged 65+ or Blind - "DAB" or "SSI-Related" Category -- NON-MAGI - See this chart for their household size.   These same rules apply to the Medicare Savings Program, with some exceptions explained in this article

  2. Everyone else -- MAGI - All children and adults under age 65, including  people with disabilities who are not yet on Medicare -- this is the new "MAGI" population.  Their household size will be determined using federal income tax rules, which are very complicated.

New rule is explained in State's directive 13 ADM-03 - Medicaid Eligibility Changes under the Affordable Care Act (ACA) of 2010  (PDF)  pp. 8-10 of the PDF,   This PowerPoint by NYLAG on MAGI Budgeting attempts to explain the new MAGI budgeting, including how to determine the Household Size.  See slides 28-49. Also see Legal Aid Society and Empire Justice Center materials

OLD RULE used until end of 2013 --  Count the person(s) applying for Medicaid who live together, plus any  of their legally responsible relatives who do not receive SNA, ADC, or SSI and reside with an applicant/recipient.   Spouses or legally responsible for one another, and parents are legally responsible for their children under age 21  (though if the child is disabled, use the rule in the 1st "DAB" category.    Under this rule, a child may be excluded from the household if that child's income causes other family members to lose Medicaid eligibility.    See 18 NYCRR 360-4.2,  MRG p. 573,  NYS GIS 2000 MA-007

  • CAUTION:   Different people in the same household may be in different "categories" and hence have different household sizes AND  Medicaid income and resource limits.  If a man is age 67 and has Medicare and his wife is age 62 and not disabled or blind, the husband's household size for Medicaid is determined under Category 1/ Non-MAGI above and his wife's is under Category 2/MAGI.  

The following programs were available prior to 2014, but are now discontinued because they are folded into MAGI Medicaid:

  • Prenatal Care Assistance Program (PCAP) was Medicaid  for pregnant women and children under age 19, with higher income limits for pregnant woman and infants under one year (200% FPL for pregnant women receiving perinatal coverage only not full Medicaid) than for children ages 1-18 (133% FPL).  

  • Medicaid for adults between ages 21-65 who are not disabled and without children under 21 in the household. It was sometimes known as "S/CC" category for Singles and Childless Couples.  This category had lower income limits than DAB/ADC-related, but had no asset limits.  It did not allow "spend down" of excess income.  This category has now been subsumed under the new MAGI adult group whose limit is now raised to 138% FPL.

  • Family Health Plus - this was an expansion of Medicaid to families with income up to 150% FPL and for childless adults up to 100% FPL.  This has now been folded into the new MAGI adult group whose limit is 138% FPL.  For applicants between 138%-150% FPL, they will be eligible for a new program where Medicaid will subsidize their purchase of Qualified Health Plans on the Exchange.

PAST INCOME & RESOURCE LEVELS --

Past Medicaid income and resource levels in NYS are shown on these old NYC HRA  charts for 2001 through 2013, in chronological order.  These include Family Health Plus, Child Health Plus, MBI-WPD, Medicare Savings Programs and other public health programs in NYS. 


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
file MAPDR-01 2014 NYS Income and Resource Standards and FPL 6-24-2014.pdf (153 kb)
file HOUSEHOLD SIZE FOR SSI RELATED CHART.pdf (205 kb)
file 2001_to_2013_income__rsource_level_charts.pdf (2.24 mb)
file NYLAG ACA Part 2 - MAGI.ppt (2.72 mb)

Also read
document Transfer of Asset Rules in Medicaid -- The Deficit Reduction Act of 2005
document Family Health Plus Overview
document Keeping Medicaid after Cash Public Assistance or SSI Benefits Are Terminated
document Elimination of resource test for adults in Family Health Plus and many adults in Medicaid
document Medicare Savings Programs (MSP) in New York
document Medicaid Resource and Income Disregards
document New Application Form (2010) Used for Medicaid, Child Health Plus and Family Health Plus in New York State
document Affordable Care Act --New York State Health Exchange Open Year-Round for Medicaid Applications and for Certain "Special Enrollment" categories
document KNOW YOUR RIGHTS: Fact Sheet Explaining Basic Rules on NYS Financial Medicaid Eligibility for People who are Disabled, Aged 65+, or Blind
document The Affordable Care Act Implementation: New Opportunities and New Hurdles for Low-Income Communities in New York City
document NYS DOH releases more directives on Medicaid changes under the Affordable Care Act
document The Affordable Care Act Implementation: Medicaid Expansion and MAGI Budgeting
document Medicaid in 2014: Understanding MAGI & the Marketplace

External links
MAPDR-01
http://www.health.state.ny.us/health_care/medicaid/publications/docs/gis/10ma026.pdf

Also listed in
folder Federal Health Reform

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Financial Eligibility     Medicaid in 2014: Understanding MAGI & the Marketplace


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