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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyNew Mexico HCA SSI Extensions WDI MSPs Coverage | …
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    CurrentNew Mexico Health Care AuthorityPolicy N/A

    AGED, BLIND AND DISABLED — SSI Extensions, WDI, MSPs, and IC/Waiver Coverage Criteria

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    Defines income, resource, and program rules for SSI extensions (DAC, Widower, 503 Lead/Pickle), Working Disabled Individuals (WDI), Medicare Savings Programs (QMB, SLIMB, QI/Q1), IC/Waiver, and related coverage determinations for beneficiaries in New Mexico's aged, blind, and disabled Medicaid population.

    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyAGED, BLIND AND DISABLED — SSI Extensions, WDI, MSPs, and IC/Waiver Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2022
    Next Review DateN/A
    Key ActionApply specified income and resource limits to determine eligibility for SSI extensions, WDI, Medicare Savings Programs, and IC/Waiver categories.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Individual FBR $841SSI monthly federal benefit rate used for eligibility
    WDI up to 250% FPLWorking Disabled income allowance
    QMB up to 100% FPLQualified Medicare Beneficiary income limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Part B premium $170.10
    Amount covered under Medicare Savings Programs
    Resource limit $2,000SSI-related resource limit

    Eligibility and Coverage Criteria for Aged, Blind, and Disabled

    Coverage criteria for AGED, BLIND AND DISABLED programs

    Eligibility criteria and benefits for specific categories:

    ALL of the following

    • Income must be below the SSI Federal Benefit Rate (FBR) after applicable disregards

      FBR amounts: Individual $841; Couple $1,261

    • Resources must be below the specified limit

      Resource limits: Individual $2,000; Couple $3,000

    • Categorized as full coverage Medicaid

    ALL of the following

    • Member must be working and be disabled as determined by SSA or DDU (age 65 alone does not qualify as disabled)
    • Earned income allowed up to 250% of Federal Poverty Level (FPL) for single and couple

      Unearned income limits before disregards: Single $1,701; Couple $2,541

    • Quarterly earnings limit applies

      Quarterly earnings limit: $1,510

    • Categorized as full coverage Medicaid

    ALL of the following

    • QMB (Qualified Medicare Beneficiary)

      • Income up to 100% FPL
      • Will pay conditional Part A premium
      • Eligibility begins the month after approval; no retroactive months

    • SLIMB (Specified Low-Income Medicare Beneficiary)

      • Income 100%–120% FPL
      • Will NOT pay conditional Part A
      • Eligibility begins the month of approval; up to 3 months retroactive coverage

    ALL of the following

    • Income and net income standards apply

      Income standard $2,523; Net income for IDTs $2,522

    • Resource limit applies

      Resource limit $2,000

    • Other financial parameters used in eligibility and cost calculations

      Average nursing facility cost $7,811; MMMNA $2,178; Excess shelter max $1,257 min $653; MMMNA + Excess Shelter = $3,435; CSRA-Fed Max $137,400; CSRA-State Min $31,290; Personal Needs Allowance $78; Trustee fee 3%/net income standard $75.66; Excess home equity for LTC services $636,000

    ALL of the following

    • MSP categories can result in payment of Medicare Part B premium, Part A premium, copays and deductibles depending on the specific MSP

      Example amounts referenced: Medicare Part B premium $170.10 (2022); Medicare Part A premium $499 (2022)

    • Resource guidelines do not apply to MSP categories (QMB/SLIMB/QI1)
    • Qualified MSP beneficiaries are deemed eligible for Low-Income Subsidy (LIS) for Medicare Part D

    Coding and Income Threshold References

    Income thresholds (FPL bands)
    Working Disabled Individuals (WDI)Earned income allowed up to 250% FPL (single and couple).
    Qualified Medicare Beneficiary (QMB)Income up to 100% FPL — pays conditional Part A premium; eligibility begins the month after approval with no retroactive months.
    Specified Low-Income Medicare Beneficiary (SLIMB)Income 100%–120% FPL — does NOT pay conditional Part A; eligibility begins month of approval; up to 3 months retroactive coverage.
    Qualified Individuals (Q1-1)Income 120%–135% FPL — does NOT pay conditional Part A; eligibility begins month of approval; up to 3 months retroactive coverage.

    Authorization and Provider Guidance

    Prior Authorization

    Authorization / Prior Authorization — None specified in this policy

    This document does not establish any prior authorization or authorization requirements. It provides eligibility and benefit parameters for SSI Extensions (DAC, Widower, 503 Lead/Pickle), Working Disabled Individuals (WDI), Medicare Savings Programs (QMB, SLIMB, QI/Q1), and IC/Waiver categories; providers should not expect prior authorization rules within this policy and must follow separate authorization guidance if required for services outside these eligibility determinations.

    • No prior authorization rules are specified in this document; it details eligibility and benefit parameters for SSI extensions, WDI, MSPs, IC/Waiver, and Qualified Individuals.
    • If services require prior authorization, providers must rely on the applicable clinical or program-specific authorization policies rather than this eligibility document.

    Program Definitions and Key Terms

    SSI Extensions — DAC, Widower, 503 Lead/Pickle
    DAC / Widower / 503 Lead (Pickle)SSI Extensions group where income must be below the SSI Federal Benefit Rate after disregards are deducted; full coverage Medicaid category.
    SSI Federal Benefit Rate (FBR) — Individual$841 (monthly) — used as the income standard for SSI Extensions after disregards.
    SSI Federal Benefit Rate (FBR) — Couple$1,261 (monthly).
    Resource limitsResources below $2,000 for an individual and $3,000 for a couple to qualify.
    WDI — Working Disabled Individuals
    DefinitionWorking Disabled Individuals (WDI): individuals who are working and disabled (disability determined by SSA or DDU).
    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyAGED, BLIND AND DISABLED — SSI Extensions, WDI, MSPs, and IC/Waiver Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 2022
    Next Review DateN/A
    Key ActionApply specified income and resource limits to determine eligibility for SSI extensions, WDI, Medicare Savings Programs, and IC/Waiver categories.
    SourceLink
    On This Page
    Eligibility and Coverage Criteria for Aged, Blind, and DisabledCoding and Income Threshold ReferencesAuthorization and Provider GuidanceProgram Definitions and Key Terms

  1. Qualified Individuals (Q1-1)

    • Income 120%–135% FPL
    • Will NOT pay conditional Part A
    • Eligibility begins the month of approval; up to 3 months retroactive coverage
    2. Earned income allowanceEarned income up to 250% FPL for single and couple households.
    Unearned income limits (pre-disregards)Single: $1,701; Couple: $2,541 (values shown before disregards and deductions).
    Quarterly earnings limit$1,510 per quarter.
    Medicare Savings Programs (QMB, SLIMB, QI/Q1)
    QMB (Qualified Medicare Beneficiary)Income up to 100% FPL — pays conditional Part A premium; covers Medicare Part A/B premiums, copays and deductibles; eligibility begins the month after approval with no retroactive months.
    SLIMB (Specified Low-Income Medicare Beneficiary)Income 100%–120% FPL — covers Medicare Part B premium only; will NOT pay conditional Part A; eligibility begins month of approval; up to 3 months retroactive coverage.
    QI / Q1-1 (Qualified Individuals)Income 120%–135% FPL — covers Medicare Part B premium only; will NOT pay conditional Part A; eligibility begins month of approval; up to 3 months retroactive coverage.
    MSP benefits and Part DMedicare Savings Program beneficiaries are deemed eligible for LIS for Medicare Part D; 2022 Part B premium listed as $170.10 and Part A premium $499 (contextual benefit amounts).
    IC/Waiver — Institutional Care/Waiver financial standards
    Income standardIncome standard $2,523 (IC/Waiver).
    Net income for IDTsNet income for IDTs $2,522.
    Resource limitResource limit $2,000.
    Average nursing facility costAverage cost of nursing facility $7,811.
    Other financial parametersMMMNA $2,178; Excess shelter max $1,257 / min $653; Personal Needs Allowance $78; Excess home equity limit $636,000 (values shown with 7/2021 references).