2012 NYS INCOME AND RESOURCE STANDARDS AND FEDERAL POVERTY LEVELS (FPL)

Effective 01/01/12
Reference Documents: GIS 11 MA/027, SA 2011-00362-00 R9, SA 2011-00863-00 MAPDR-01 12/23/2011

1.

Medicaid for Pregnant Women and Medicaid Monthly Income Levels (Pregnant Women and Children Under 19)
Each Addl Person

Family Size
Children under 1 yr; Pregnant Women Perinatal Coverage Only (200% FPL) Children 1-18 yrs (133% FPL) Children 19-20 yrs; Parents/Disabled Individuals Pregnant Women (count as 2 people) Full Coverage (100% FPL) 2.

1 $1,815 $1,207 $792

2 $2,452 $1,631 $1,159 $1,226

3 $3,089 $2,054 $1,333 $1,545

4 $3,725 $2,478 $1,506 $1,863

5 $4,362 $2,901 $1,680 $2,181

6 $4,999 $3,324 $1,854 $2,500

$637 $424 $174 $319

Child Health Plus Premium Levels Monthly Income Monthly Income by Family Size (Children Under 19 NOT Medicaid Eligible) Note: The dollar amounts highlighted below are the result of local calculations and are subject to further change after the revised FPL values are published in the Federal Register. Premium Categories Free Insurance (Less than 160% FPL) $9 per child per month (Max. $27 per family) (222% FPL) $15 per child per month (Max $45/Family) (250% FPL) $30 per child per month (Max. $90 per family) (300% FPL) $45 per child per month (Max. $135 per family) (350% FPL) $60 per child per month (Max. $180 per family) (400% FPL) Full Premium per child/month if over 400% FPL (Premium amount varies from plan to plan) 3.
1 $1,452 $2,016 $2,269 $2,724 $3,178 $3,632 Over $3,632 2 $1,962 $2,722 $3,065 $3,678 $4,291 $4,904 Over $4,904 3 $2,471 $3,430 $3,863 $4,635 $5,408 $6,180 Over $6,180 4 $2,980 $4,136 $4,658 $5,589 $6,521 $7,452 Over $7,452 5 $3,490 $4,842 $5,453 $6,543 $7,634 $8,724 Over $8,724 6 $3,999 $5,550 $6,250 $7,500 $8,750 $10,000 Over $10,000
Each Addl Person

$510 $708 $798 $957 $1,117 $1,276 $1,274

Regular Medicaid Levels (Parents, 19 and 20 year olds, disabled or blind 21-64 year olds, persons 65 and over) [Income level testing applies to all. Resource level testing applies only to disabled or blind 21-64 year olds and persons 65 and over]
1 $792 $14,250 2 $1,159 $20,850 3 $1,333 $23,978 4 $1,506 $27,105 5 $1,680 $30,233 6 $1,854 $33,360 7 $2,028 $36,488 8 $2, 201 $39,615 9 $2,375 $42,743 10 $2549 $45,871
Each Addl Person

Family Size Monthly Income Resource Level

$174 $3,128

4. (a)
Family Size FHP Limit 150% FPL

FHP Income Levels (Parents Living with Children Under 21 in their Household; 19-20 year olds living with their parents)
1 $1,362 2 $1,839 3 $2,317 4 $2,794 5 $3,272 6 $3,749 7 $4,227 8 $4,704 9 $5,182 10 $5,659 Each Addl Person $478

4. (b)

FHP Income Levels (Adults Without Children Under 21 in Household and 19-20 Year Olds Living Alone)
Family of 1 Family of 2 $908 $1,226

INCOME LEVELS (100% FPL)

MAPDR-01 (Rev. 12/23/2011)

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5. Family Planning Benefit Program Income Levels (No Resource Test)

Family Size FPBP 200% FPL (Child Bearing Age) 1 $1,815 2 $2,452 3 $3,089 4 $3,725 5 $4,362 6 $4,999
Each Addl Person

6.

MBI-WPD (Persons 16-64)

Note: The dollar amounts highlighted below are 2011 levels. Revised 2012 levels are pending release.
Family Size MBI-WPD 250% FPL 1 $2,269 2 $3,065 (1) (2) Resource $20,000 $30,000

$637

7.
Family Size Monthly Income

Monthly Medicaid Standards Non-Disabled Adults ages 21-64 Without Children under 21 in the Household and Low Income Families)
1 $735 2 $918 3 $1,092 4 $1,268 5 $1,450 6 $1,582 7 $1723 8 $1,902 9 $2,006 10 $2,110
Each Addl Person

$104

8.

Medicare Savings Program (Buy-In) [Excludes $20 Disregard] Income Family of 1 Family of 2
$14,710 $1,226 $17,652 $1,471 $19,859 $ 1,655

9.

Other Important Figures

Note: The dollar amounts highlighted below are 2011 levels. Revised 2012 levels are pending release. Medicare Part A Premium: $248.00 (30-39 Quarters)
$451.00 (Less than 30 Quarters)

QMB 100% FPL SLIMB 120% FPL

Annual Monthly Annual Monthly Annual Monthly

$10,890 $ 908 $13,068 $1,089 $14,702 $1,226

Medicare Part B Premium: $99.90 for all recipients Standard Allocation: From non-SSI-related parent to non-SSI-related child $367 PASS-THROUGH FACTORS: .966 and .168 Family Size COBRA (100% FPL) AIDS Health Ins. Program (AHIP) (185% FPL) QWDI (200% FPL) COBRA, QWDI (Resource Level) Pickle/DAC/SSI (Resource Level) 1 $ 908 $1,679 $1,815 $4,000 $2,000 2 $1,226 $2,268 $2,452 $6,000 $3,000

QI-1 135% FPL

NO RESOURCE TEST FOR ANY MSP PROGRAM 10.

INCOME (MMMNA) - $2,841

Spousal Support and Resource Level s

Note: The dollar amounts highlighted below are 2011 levels. Revised 2012 levels are pending release.
RESOURCES (Minimum) - $74,820 (Maximum) - $113,640 FAMILY MEMBER ALLOWANCE FORMULA: USE - $1,839 $ 613 is the maximum family member allowance

11.
Family Size FHP Limit 150% FPL 1 $14,250 2 $20,850 3 $23,978 4

SSI Related Resource Levels

5 $30,233 6 $33,360 7 $36,488 8 $39,615 9 $42,743 10 $45,871 Each Addl Person $3,128

$27,105

12.

Monthly Regional Nursing Home Rates

Note: The dollar amounts highlighted below are 2011 levels. Revised 2012 levels are pending release. LONG ISLAND - $11,445 Nassau, Suffolk NEW YORK CITY (All boroughs) - $10,579 NORTHEASTERN - $8,323 Albany, Clinton, Columbia, Delaware, NORTHERN METROPOLITAN - $10,105 Duchess, Orange, Putnam,
Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington WESTERN (Buffalo) - $7,863 Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming Rockland, Sullivan, Ulster, Westchester

ROCHESTER - $8,942 Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates

CENTRAL (Syracuse) - $7,688

Broome,Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga, Tompkins

In determining the community resource allowance on and after January 1, 2009, the community spouse is permitted to retain resources in an amount equal to the greater of the following: $74,820 or the amount of the spousal share up to $113,640. The spousal share is the amount equal to one-half of the total value of the ountable resources of the couple as of the date of the first continuous period of institutionalization of the institutionalized spouse on or after September 30, 1989. The look-back period anchored in the month the A/R is both institutionalized and applying for MA

MAPDR-01 (Rev. 12/23/2011)

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