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MACPAC > Eligibility > Elderly

Elderly

Published On

March 03, 2020

Over 6.9 million Medicaid beneficiaries were age 65 or older in fiscal year 2013, and nearly all (6.4 million) were dually eligible for Medicare and Medicaid.

Supplemental Security Income (SSI) is a federal program providing cash assistance to low-income people with disabilities (under age 65) and people age 65 and older. For people age 65 and older, there is no disability determination required to obtain SSI as low income and assets alone qualify them for SSI.

In most states, SSI beneficiaries are a mandatory population for state Medicaid programs and are automatically eligible for Medicaid. Medicaid programs may also offer eligibility to people age 65 and older through other optional pathways allow countable income and assets above SSI levels. These include:

  • Poverty level. States have the option to cover people with disabilities with income or assets above the level permitted for SSI eligibility.
  • Medically needy. Under this option, people with disabilities who have higher incomes can spend down to a state-specified medically needy income level by incurring medical expenses.
  • Special income level. Under this option, states can cover institutionalized individuals with incomes up to 300 percent of the SSI benefit rate (approximately $2,199 per month for an individual, or 222 percent FPL); states may also extend this eligibility to individuals who receive home and community- based waiver services as an alternative to institutionalization.
  • Home and community-based services (HCBS). States may extend eligibility to individuals who receive certain HCBS and require an institutional level of care or meet other needs-based criteria that assess functional status.

For more on Medicaid eligibility, see Federal Requirements and State Options: Eligibility.

TABLE 1. Eligibility Pathways for Individuals Age 65 and Older

Eligibility group Federal statutory and regulatory requirements State plan options
Aged individuals (age 65 and older) Aged individuals receiving Supplemental Security Income (SSI)

  • States must provide Medicaid coverage to individuals age 65 or older receiving SSI or who would have been eligible for SSI on the basis of their low income and assets.1
 SSI-related pathways

  • Other optional individuals age 65 or older can be covered under certain SSI-related provisions.

Optional poverty and low-income-related pathways

  • States have the option to cover individuals with disabilities up to 100 percent FPL or people receiving optional state supplemental payments.
  • States also have the option under the special income group option to cover institutionalized individuals with incomes not exceeding 300 percent of SSI (approximately 222 percent FPL).

Elderly< receiving services in the community

  • States have the option to cover the frail elderly living in the community who are participating in Program of All-Inclusive Care for the Elderly (PACE).
  • States have the option to cover individuals not otherwise eligible for Medicaid (under Section 1915(i)) or who would be eligible for Medicaid if institutionalized (under Sections 1915(c) and (d) waivers) who are receiving home and community-based services.
Notes: FPL is federal poverty level. Aid to Families with Dependent Children (AFDC) is the cash assistance program that was replaced by Temporary Assistance to Needy Families (TANF) in 1996. SSI is Supplemental Security Income.
1 Rather than conferring automatic Medicaid eligibility on all SSI recipients, states (referred to as 209b states) can use more restrictive criteria to determine Medicaid eligibility.
Source: MACPAC, 2017, Federal Requirements and State Options: Eligibility.
Learn more:

Data Book:  Beneficiaries Dually Eligible for Medicare and Medicaid, a joint project of MACPAC and the Medicare Payment Advisory Commission (MedPAC)

Financial Alignment Initiative for Beneficiaries Dually Eligible for Medicaid and Medicare