To be non-financially eligible for Buy-In, an individual must be entitled to Medicare Part A and/or Part B. See section 488.2, Buy-In of Medicare Part A and section 488.3, Buy-In of Medicare Part B for entitlement information. To be financially eligible for Buy-In, an applicant or recipient of LTC facility services must meet the income and resource guidelines found in Appendix A.
Based on information available in BENDEX, workers should enter a "Y" in only the appropriate Medicare entitled to and/or recipient fields on the Individual Attributes screen. This will ensure that Buy-in eligibility is correctly explored and that no Medicare Part A (600) or Part B (100) TPLs are created in error.
NOTE: For married applicants or recipients of LTC facility services, the resources and income of the non-applicant/non-recipient spouse are NOT used to determine buy-in eligibility. Only the resources and income of the applicant/recipient of LTC facility services are compared to the one-person resource and income limits.
To be resource eligible for Buy-In, an applicant or recipient of LTC facility services must have total countable resources equal to or less than the Buy-In Program resource limits and the resource limits for payment of LTC facility services. See Appendix A for the Buy-In resource limits.
Example One: Mr. A is a single individual applying for payment of LTC facility services. He owns a checking account valued at $6,390.00 and a $1,000.00 savings account. Because the $7,390.00 value of Mr. A’s total countable resources is equal to the one-person Buy-In resource limit of $7,390.00 in 2017 ($7,280.00 in 2016) and less than the LTC resource limit of $2,000.00 (with a standard $6,000.00 disregard), Mr. A is resource eligible for Buy-In and payment of LTC facility services.
Example Two: Mr. B is a married individual applying for payment of LTC facility services. He owns a checking account valued at $6,000.00 and a savings account valued at $900.00. Mrs. B owns a checking account valued at $10,000.00. Because the value of Mr. B’s total countable resources is less than the one-person Buy-In resource limit of $7,390.00 in 2017 ($7,280.00 in 2016) and because Mr. B’s total countable resources of $7390.007ligible for Buy-In and payment of LTC facility services.
To be income eligible for Buy-In, an applicant or recipient of LTC facility services must be within the Buy-In Program income limits. See Appendix A. for the Buy-In income limits.
An individual applying for or receiving payment of LTC facility services may be eligible for Buy-In as either a QMB or SLMB:
QMB: In order to be eligible as a QMB, gross monthly income (after the $20.00 unearned/earned income deduction) must be equal to or less than 100% of the Federal Poverty Income Guidelines (FPIGs) found in Appendix A.
Example One: Mr. A is a 70 year old single individual applying for payment of LTC facility services. He receives RSDI income of $599.90 and a pension of $338.00 for a total gross monthly income of $937.90.
Gross Income: $937.90
Income Deduction: - $20.00
Net Income: $917.90
The $917.90 net income is less than the $1,005.00 Buy-In income limit in 2017 ($990.00 in 2016) for one-person, so Mr. A is income eligible for payment of LTC facility services as a QMB in category PAN80.
Example Two: Mrs. B is a 50 year old married individual applying for payment of LTC facility services. She receives RSDI income of $899.90. Mr. B receives pension income of $2,500.00. The total gross monthly income used to determine Buy-In eligibility is $899.90.
Gross Income: $899.90
Income Deduction: - $20.00
Net Income: $879.90
The $879.90 net income is less than the $1,005.00 one-person Buy-In income limit in 2017 ($990.00 in 2016) so Mrs. B is income eligible for payment of LTC facility services as a QMB in category PJN 80.
SLMB: In order to be eligible as a SLMB, gross monthly income (after the $20.00 unearned/earned income deduction) must be more than 100% but less than 120% of the FPIGs found in Appendix A.
Example One: Mr. C is a 50 year old single individual applying for payment of LTC facility services. He receives RSDI income of $1,120.90.
Gross Income: $1,120.90
Income Deduction: -$20.00
Net Income: $1,100.90
The $1,100.90 net income is less than the $1,205.99 one person Buy-In income limit in 2017, ($1,187.99 in 2016)so Mr. C is income eligible for payment of LTC facility services as a SLMB in category PJN 66.
Example Two: Mr. D is a 70 year old married individual applying for payment of LTC facility services. He receives RSDI income of $1,120.00. Mrs. D receives RSDI income of $800.00. The total gross monthly income used to determine Buy-In eligibility is $1,120.00.
Gross Income: $1,120.00
Income Deduction: -$20.00
Net Income: $1,100.00
The $1,100.00 net income is less than the $1,205.99 one-person Buy-in income limit in 2017, ($1,187.99 in 2016) so Mr. D is income eligible for payment of LTC facility services as a SLMB in category PAN 66.
NOTE: The $20.00 unearned/earned income deduction is limited to $20.00 per budget group.
If the individual is not entitled to Medicare and/or the individual is not financially eligible for Buy-In their eligibility for payment of LTC facility services without Buy-In must be determined. The gross income of the individual applying for or receiving payment of LTC facility services must be equal to or less than the NMP Special Income Limit which is 300% of the Federal Benefit Rate (FBR), currently $2,205.00 in 2017 ($2,199.00 in 2016).
NOTE: The $20 unearned/earned income deduction is not used to determine eligibility for payment of LTC facility services. The deduction is only used to determine eligibility for the Buy-In Program.
Example One: Mr. E is a 70 year old single individual applying for payment of LTC facility services. He receives RSDI income of $1299.90 and a pension of $700.00 for a total gross monthly income of $1,999.90.
Gross Income: $1,999.90
The $1,999.90 gross income is greater than the one-person Buy-in income limit but is less than the $2,205.00 NMP Special Income Limit in 2017, ($2,199.00 in 2016) so Mr. E is eligible for payment of LTC facility services as a PAN 00.
Example Two: Mrs. F is a 55 year old married individual applying for payment of LTC facility services. She receives RSDI income of $1,900.00. Mr. B receives Railroad Retirement Benefits of $2,000.00. The total gross monthly income of Mrs. F is $1,900.00.
Gross Income: $1,900.00
The $1,900.00 gross income of Mrs. F is greater than the one-person Buy-In income limit but is less than the NMP Special Income Limit, currently $2,205.00 in 2017, ($2,199.00 in 2016) so Mrs. F is eligible for payment of LTC facility services in a PJN 00 category.
Updated February 21, 2017 , Replacing January 4, 2017