Special Medicaid Beneficiaries

Lucy Miller

WIPA NTC

September 2009

Some Medicaid Basics

Whatever the program, people receive Medicaid coverage because they meet two criteria:– They belong to a specific covered group;

and– They meet the income and resource tests

necessary for members of that group to receive benefits.

Special Medicaid Groups

Former SSI recipients who lose eligibility for cash benefits …– for any reason, but who would have been

eligible for SSI if the SSDI COLA(s) at the point of or after SSI termination were excluded as income (Pickle People)

– because of entitlement to or an increase in CDB benefits, or

– because of entitlement to Disabled Widow(er)s Benefits (some limitations)

The Exclusions

When determining Medicaid eligibility for these special former SSI recipients, State Medicaid agencies must exclude that portion of the individual’s applicable title II disability benefit that caused ineligibility for SSI payments. That may be the entire payment, increases in the payment, or in the case of Pickle People - COLAs

What They Get If, by excluding the appropriate portion

of the title II benefit, the individual would otherwise be eligible for SSI or 1619(b), the person is deemed eligible for Medicaid.

These individuals are “deemed” SSI recipients for Medicaid purposes, though they are NOT entitled to SSI monetary benefits and are not listed on Social Security’s SSI rolls.

Clarification of Terms

The terms “SSI program” and “SSI benefits” mean the individual may either be receiving cash benefits under Title XVI (SSI) or be a 1619(b) participant who is receiving Medicaid benefits, but not SSI cash payments.

Individuals in either of these categories are considered to be receiving SSI benefits and are eligible to participate in the special Medicaid groups.

Who Determines Eligibility

State Medicaid agencies or their designees determine eligibility for Special Medicaid protections for former SSI recipients

SSA does NOT decide who is eligible, but does provide information about why SSI was lost and amount of title II payment that caused loss. This information is shared thru the SDX rolls.

The Pickle AmendmentSection 503Allows individuals who receive SSDI and lose SSI entitlement for any reason to continue Medicaid if: The individual continues to meet SSA’s

disability standard, and countable income would fall below

applicable SSI/1619(b) rate when COLA(s) are excluded

SSI resource limits are met

Eligibility for Pickle Is receiving SSDI benefits; Lost SSI, but would still be eligible for those

benefits if the total amount of the title II COLAs received since losing SSI benefits while also entitled to title II benefits was deducted from income. Cost-of-living increases include the increases by the individual, spouse or financially responsible family member; and

Was eligible for and receiving SSI concurrently with SSDI for at least one month after April 1, 1977.

Misconceptions about “Concurrently”

The individual simply needs to be “entitled” to both SSDI and SSI for the same month.

There is a one-month lag in SSDI payments, which are not disbursed until the month after entitlement while SSI payments are paid in the month of entitlement.

Even though the person never actually received simultaneous payments from both programs in a single month, he/she would meet the first Pickle requirement.

There is a common belief that the annual title II program COLA must have been the cause of the loss of SSI (or 1619(b)) in order to qualify for Pickle provisions. This is not the case and hasn’t been since a series of court decisions were made in the early 1980s!

The pivotal issue for Pickle eligibility is whether the person would otherwise be eligible for SSI or 1619(b) if the SSDI COLA(s) were deducted.

Misconception about “Causation”

Casey Example

Casey was receiving SSDI in the amount of $656 with $1 of SSI in 2008. He was not working. Casey’s 2009 cost-of-living adjustment raised his benefit to $696. Since this amount is over the current FBR +$20 ($674 + $20 = $694) in 2009, Casey is no longer eligible for SSI.What would happen to Casey’s Medicaid in this situation?

How The Pickle Amendment Helps Casey

In Casey’s situation, the Medicaid agency must exclude the increase between $656 and $696 ($40) that caused Casey to lose his SSI benefit. Since Casey has no other income and resources meet the SSI limits, he is eligible for continued Medicaid under the Pickle Amendment

Watch for Pickle People! There are many current SSDI

beneficiaries who lost SSI years ago who are potentially eligible for Medicaid under the Pickle provisions!

Eligibility for Pickle Medicaid can be established at ANY time – there is no “statute of limitations” or sunset date.

Always ask SSDI beneficiaries about former SSI eligibility and check for Pickle Medicaid eligibility

Childhood Disability Benefits

Section 1634 of the SS Act requires States to consider title II Childhood Disability Beneficiaries (CDBs) who lose SSI eligibility as if they were still SSI recipients for Medicaid purposes, so long as they would have remained otherwise eligible for SSI benefits but for their entitlement to (or increase in) CDB benefits

Lucy ExampleLucy was receiving CDB payments based on the work record of her stepmother. While the stepmother was alive, Lucy received $500.00 per month. The stepmother died recently, however, and Lucy’s CDB benefit was raised to the survivor’s benefit level of $750.00

Will Lucy keep her Medicaid?

Lucy Conclusion

The State Medicaid Agency must exclude the $250.00 difference between what Lucy was receiving before her stepmother’s death, and what she currently receives. If Lucy has no other income and has resources under the SSI limit, she would be eligible for Medicaid. If she has other income, she may or may not be eligible for Medicaid, depending on the type and amount of the income.

Cindy Example

Cindy is 20 and receives SSI. Her mother retired and applied for Social Security Retirement Insurance Benefits. Her mother had high earnings, and Cindy’s payment as a CDB based on her mother’s work will be $700.00 per month. What might happen to Cindy’s Medicaid in this situation?

Cindy Conclusion

Since Cindy had no Childhood Disability Benefits before her mother retired, the state must exclude all of Cindy’s CDB benefits when determining her eligibility for Medicaid If Cindy has other income or countable resources it might affect her entitlement to Medicaid.

Disabled Widow(er)s Benefits

In 1991, The SS Act was amended so that any former SSI eligible widow(er) will be considered by the state to be an SSI recipient for Medicaid purposes who:

would continue to be eligible for SSI benefits but for their DWB benefits and COLAs;

received an SSI benefit the month before their DWB payments began; and

is not entitled to Medicare Part A, until they become entitled to Medicare Part A.

Qualifying Period and DWBNOTE: When a former SSI recipient is found entitled to DWB benefits, all months on the SSI rolls at any time are credited concurrently against the 5-month disability waiting period and 24-month Medicare Qualifying Period. That means that Medicare coverage may begin with first month of DWB payments.

The state Medicaid agency’s ability to exclude DWB when determining entitlement to Medicaid ends with entitlement to Medicare Part A. At this point, be sure to check for QMB/SLMB eligibility!

Other Income Eligibility for special Medicaid benefits is

strictly related to being otherwise eligible for SSI or 1619(b).

The challenge is predicting when these individuals involved will lose Medicaid coverage. There is no easy way to predict because it depends entirely on how much of the Social Security disability benefit is excluded, and on how much and what types of other income the beneficiary receives.

Income limits

All states must use the same income/resource eligibility rules for SSI Medicaid recipients and Special Medicaid Beneficiaries. Rules may differ from state to state (209b states in particular), but must be consistent between these programs. Know your state rules!

Interaction between Special Medicaid Benefits and 1619(b)

Individuals in 1619(b) status are considered to be SSI eligible, simply not in cash payment status

If a person would be eligible for either SSI or 1619(b) status after the applicable title II disability payments (or portions of payments) are disregarded under Special Medicaid rules, Medicaid eligibility should be established.

The Burning Question…….

How much can a Special Medicaid Beneficiary earn without losing Medicaid?

Factors to Consider Is the individual a member of one of the three

special protected classes? How much of the individual’s title II benefit can be

excluded? Does the individual have other unearned income,

including in-kind support? What is the aged, blind and disabled income limit

for individuals in your state including any applicable state supplements?

If the beneficiary is working, what is the threshold amount in your state?

Does the individual have excess resources?

Income and Special Medicaid Benefits

Examples with other forms of unearned income and earned income

Retaining Special Medicaid Status

Individuals who lose Special Medicaid entitlement due to other income, may return to this status if income drops, and exclusion of appropriate title II would make the individual again eligible for Medicaid. This may occur at any time in the future.

Note: DWBs may not retain Special Medicaid status after Medicare coverage begins.

Challenges

In order to correctly calculate Medicaid eligibility, the State must establish:

That the person lost SSI entitlement under one of these special circumstances,

The amount the individual was receiving in title II benefits before the SSI entitlement or 1619(b) was lost and,

Amounts and types of other income the individual receives at the time the decision is being made.

Additional Challenges

Individual involved may not know, or understand that this exclusion might exist.

Medicaid worker also may not know about the Special Medicaid protections and thus does not apply the exclusion.

Medicaid workers often do not understand 1619(b) status and how it applies to Special Medicaid beneficiaries.

The income exclusion rules are not always interpreted nor applied correctly.

CWIC Responsibilities Know your state Medicaid eligibility rules for

SSI recipients – get the regulations! Develop relationships within the agency that

makes Medicaid eligibility determinations Recognize these special groups exist, and

facilitate Medicaid entitlement if necessary Expect eligibility determination problems and

work proactively to avoid them when possible. Educate beneficiaries on their appeal rights.

Refer to PABSS when necessary!