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New Medicaid Income Limits Expand Eligibility for Duals and Medically Needy

The income limits for Medicaid coverage through the Qualified Medicare Beneficiary (QMB) and Medically Needy categories of eligibility were raised to 138 percent of the Federal Poverty Level (FPL), effective Jan. 1, 2023. The new income limit is equivalent to about $18,756 annually for a household of one. It represents an increase from 100 percent of the FPL for the QMB category. For beneficiaries in the Medically Needy category, the new limit is an increase from $11,208 in 2022. Due to this change, more individuals qualify for these benefits.

The resource limit for Medically Needy, Supplemental Security Income (SSI)-related individuals has also increased from $16,800 ($24,600 for a couple) for 2022 to $28,133 for an individual ($37,902 for a couple), effective Jan. 1, 2023. In addition, the resource limit for the Medicaid Buy-In Program for Working People with Disabilities (MBI-WPD) has increased to the same amount as the Medically Needy resource levels. The income level for MBI-WPD remains 250 percent of the FPL.

Providers should be aware that eligibility responses for individuals with QMB coverage in the Electronic Provider Assisted Claim Entry System (ePACES) will indicate active Medicare and include "QMB" as a suffix to the type of Medicare in which the individuals are enrolled. There are no changes to the billing process for New York State Medicaid members enrolled in the Medicare Savings Program (MSP) at the QMB level.

DOH anticipates that many individuals with excess income will experience a reduction in the amount of excess income and in their associated "spenddown" obligation. This includes Medicaid members currently enrolled in a Managed Long Term Care (MLTC) plan who are currently paying their excess income ("spenddown") amount to the MLTC plan.

If a refund is due to the MLTC plan enrollee as a result of a recalculation of income, DOH has instructed MLTC plans to issue a refund retroactive to Jan. 1, 2023, when updated spenddown amounts are received by the plan (through a copy of a Notice with the budget change issued by the local department of social services (LDSS) or through an 834 transaction).

Further information can be found in the February 2023 DOH Medicaid Update and in DOH General Information System (GIS) message 22 MA 11.

MLTC plans should direct questions to mltcinfo@health.ny.gov, with the email subject line "MLTC Spenddown Recalculation Refund," or 518-474-6965. Medicaid member-specific questions regarding personal spenddown recalculations should be directed to the member's LDSS or the New York City Human Resources Administration (HRA).

Contact: Karen Lipson, klipson@leadingageny.org