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 will check 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: Adam is a single individual applying for payment of LTC facility services. Adam owns a checking account valued at $6,400.00 and a $1,000.00 savings account. Because the $7,400.00 value of Adam’s total countable resources is less than the one-person Buy-In resource limit of $8,000.00 in 2022 ($7,970.00 in 2021) and less than the LTC resource limit of $2,000.00 (with a standard $6,000.00 disregard), Adam is resource eligible for Buy-In and payment of LTC facility services.
Example Two: Brian is a married individual applying for payment of LTC facility services. Brian owns a checking account valued at $6,000.00 and a savings account valued at $900.00. Barbara, Brian's wife, owns a checking account valued at $10,000.00. Because the $6,900.00 value of Brian’s total countable resources is less than the one-person Buy-In resource limit of $8,000.00 in 2022 ($7,970.00 in 2021) and because Brian’s total countable resources of $6,900.00, are less than the $2,000.00 (with a standard $6,000.00 disregard) limit he is eligible for Buy-In and payment of LTC facility services.
NOTE: In 2022 the buy-in limit for one-person increased above the LTC facility resource limit of $2,000.00 with a standard $6,000.00 disregard. Since a LTC applicant or recipient cannot have countable resources exceeding $8,000.00 and be eligible for LTC facility services, the buy-in resource limit for LTC facility applicants/recipients is $8,000.00.
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. When determining eligibility for Buy-In the Healthy Horizons unearned and earned income deductions found in MAEH 319.7 apply to the Buy-In determination. Net income after these allowable deductions must be within the Buy-In income limits listed in Appendix A.
The CAO will use Healthy Horizons rules found in MAEH 319.7 when determining eligibility for QMB and SLMB benefits. 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 and other unearned income deductions) must be equal to or less than 100% of the Federal Poverty Income Guidelines (FPIGs) found in Appendix A.
Example One: Arthur is a 70 year old single individual applying for payment of LTC facility services. Arthur receives RSDI income of $600.00 and a pension of $340.00 for a total gross monthly income of $940.00.
Gross Income: $940.00
Income Deduction: - $20.00
Net Income: $920.00
The $920.00 net income is less than the $1,133.00 Buy-In income limit in 2022 ($1,074.00 in 2021) for one-person, so Arthur is income eligible for payment of LTC facility services as a QMB in category PAN80.
Example Two: Bonnie is a 50 year old married individual applying for payment of LTC facility services. Bonnie receives RSDI income of $900.00. Bob, Bonnie’s spouse, receives pension income of $2,500.00. The total gross monthly income used to determine Buy-In eligibility is $900.00.
Gross Income: $900.00
Income Deduction: - $20.00
Net Income: $880.00
The $880.00 net income is less than the $1,133.00 one-person Buy-In income limit in 2022 ($1,074.00 in 2021) so Bonnie 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 and other unearned income deductions) must be more than 100% but less than or equal to 120% of the FPIGs found in Appendix A.
Example One: Charles is a 50 year old single individual applying for payment of LTC facility services. Charles receives RSDI income of $1,200.00.
Gross Income: $1,200.00.
Income Deduction: -$20.00
Net Income: $1,180.00
The $1,180.00 net income is less than the $1,358.99 one person Buy-In income limit in 2022, ($1,287.99 in 2021) so Charles is income eligible for payment of LTC facility services as a SLMB in category PJN 66.
Example Two: Daryl is a 70-year-old married individual applying for payment of LTC facility services. Daryl receives RSDI income of $1,220.00. Donna, Daryl’s spouse, receives RSDI income of $800.00. The total gross monthly income used to determine Buy-In eligibility is $1,220.00.
Gross Income: $1,220.00
Income Deduction: -$20.00
Net Income: $1,200.00
The $1,200.00 net income is less than the $1,358.99 one-person Buy-in income limit in 2022, ($1,287.99 in 2021) so Daryl is income eligible for payment of LTC facility services as a SLMB in category PAN 66.
Example Three: Eddie is a 71-year-old single individual applying for payment of LTC. Eddie receives RSDI income of $1,330.00 per month. Eddie spends $20.00 per month on transportation to retrieve income from the bank and $15.00 per month in bank fees.
Gross
Income: $1,330.00
Transportation & bank fees: -$35.00
Income Deduction: -$20.00
Net Income: $1,275.00
The $1,275.00 net income is less than the $1,358.99 one-person Buy-In income limit for 2022 ($1,287.99 in 2021), so Eddie is income eligible for payment of LTC 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 $2,523.00 in 2022 ($2,382.00 in 2021).
NOTE: The $20 unearned/earned income deduction is not used to determine eligibility for payment of LTC facility services. The unearned income deductions are only used to determine eligibility for the Buy-In Program.
Example One: Fred is a 70-year-old single individual applying for payment of LTC facility services. Fred receives RSDI income of $1,300.00 and a pension of $700.00 for a total gross monthly income of $2,000.00.
Gross Income: $2,000.00
The $2,000.00 gross income is greater than the one-person Buy-In income limit but is less than the $2,523.00 NMP Special Income Limit in 2022, ($2,382.00 in 2021) so Fred is eligible for payment of LTC facility services as a PAN 00.
Example Two: Gertrude is a 55-year-old married individual applying for payment of LTC facility services. Gertrude receives RSDI income of $1,900.00. Gary, Gertrude’s spouse, receives Railroad Retirement Benefits of $2,000.00. The total gross monthly income of Gertrude is $1,900.00.
Gross Income: $1,900.00
The $1,900.00 gross income of Gertrude is greater than the one-person Buy-In income limit but is less than the NMP Special Income Limit, currently $2,523.00 in 2022, ($2,382.00 in 2021) so Gertrude is eligible for payment of LTC facility services in a PJN 00 category.
Updated June 15, 2022, Replacing February 3, 2022