NMP coverage is extended for an individual who becomes ineligible for SSI because of special circumstances. The CAO will determine whether any of the following situations applies when SSI is closed, when an individual applies for MA, or when MA is renewed.
If an individual is eligible for extended NMP under one of the special situations discussed in this section, the CAO will approve MA in an SSI-related category (PA, PJ, or PM).
When an individual is determined eligible for one of the following programs, CIS will automatically send a notice after processing. Copies of the notices may be found in Appendix C, SSI Form Letters and Notices.
The Pickle amendment, as expanded by the Lynch v. Rank court decision, provides for the disregard of Social Security Title II RSDI cost-of-living increases when an individual who is getting both SSI and RSDI is found ineligible for SSI because of the increase in the RSDI income. The CAO must determine the individual’s eligibility for NMP as it would for any other SSI individual, but it must not count any RSDI COLAs that the individual received since the SSI closure. Eligibility for NMP is determined using the RSDI benefit received in the last month of SSI eligibility.
NOTE: The CAO will count any increases in RSDI that were given for reasons other than a COLA.
To qualify for NMP under the Pickle amendment, all of the following conditions must be met:
The individual currently gets Social Security Title II RSDI benefits.
The individual received Social Security Title II RSDI and SSI at the same time in any month after April 1977.
SSI benefits were stopped after April 1977.
The individual received a Social Security Title II COLA since SSI was stopped, and he or she is currently ineligible for SSI.
The individual would be eligible for SSI if the Social Security Title II COLAs received after SSI ineligibility were not counted.
The Social Security Administration (SSA) has given DPW a tape listing individuals who received SSI and Social Security benefits at the same time and whose SSI benefits were stopped after April 1977. The individuals listed on the tape might be eligible for NMP under the Pickle amendment. The information is available for the CAO to review on MAPPER. The tape is updated at regular times. The CAO must access the file for information if a former SSI recipient applies for benefits.
The file includes information about the individual’s SSI stop date and Title II (RSDI) benefit amount at the time he or she lost SSI. The CAO can get information using the individual’s claim account number or last name. The claim account number gives the “Current Title II Benefit Amount.” Do not use this information, as the amount may not be correct. Instead, make a surname inquiry by entering the following information:
Transaction code: MAPPER
Signon: ]SSN,157,Password
Action: M8E012
Claim account number: Enter the first nine digits of the Social Security claim number. Do not enter letters.
Surname inquiry: Enter the surname (last name). You must enter at least one letter and no more than eleven letters. The screen will list possible names in alphabetical order. Use the list to get the correct individual’s Claim Account Number.
If an individual receives Title II Social Security benefits, the CAO will ask the individual whether he or she ever received SSI. If the individual meets the conditions above, the CAO will determine the individual’s eligibility for PA, PJ, or PM as follows: 55 Pa. Code § 141.71(b)(5)
Obtain the current monthly countable income amount from IEVS Exchange #3, BENDEX Match, and from other information in the case record.
Determine the amount of any Title II Social Security RSDI COLAs the individual received after SSI was stopped.
Subtract the total COLA amount from the current Title II Social Security RSDI benefit.
If the net income after excluding the COLA is the same as or less than the current SSI benefit rate, close the A, J, or M category and approve PA, PJ, or PM. CIS will determine a renewal date of twelve months from the approval date.
If the net income after excluding the COLA is more than the current SSI benefit rate, and the individual is not eligible for SSI-related NMP, determine whether the individual is eligible for the Healthy Horizons categorically needy or Healthy Horizons cost-sharing program.
If the individual is eligible for Medicare, DPW will pay the individual’s Medicare premium. Assign the correct program status code to the category to enroll the individual in Buy-In.
When the CAO gets an IEVS Exchange #6 disposition reason alert indicating that an individual is ineligible for SSI because of a Title II Social Security benefit increase, the CAO will:
Send a confirming notice to stop MA in the SSI category.
Approve MA in the NMP category (PA, PJ, or PM). The effective date is the day after the closing date of SSI MA benefits.
Send the individual a notice of eligibility for his or her new MA category.
Review the individual’s eligibility if a change takes place because of any of the following:
An increase in the individual’s income other than from a COLA.
An increase in the individual’s resources.
A change from individual to couple status.
A change in the individual’s living situation.
A Disabled Adult Child (DAC) receives Title II Social Security DAC benefits when his or her parent becomes disabled, retires, or dies.
A Disabled Adult Child who loses SSI benefits because he or she has an increase in Title II Social Security benefits may continue to be eligible for NMP.
Disabled Adult Children who are eligible for NMP are also eligible for buy-in if they get Medicare Part B.
A Disabled Adult Child is an individual who:
Became disabled or blind before age 22.
Receives or is eligible to receive Title II Social Security child’s insurance benefits as a dependent of a retired, disabled, or deceased parent.
A Disabled Adult Child is eligible for NMP if all of the following conditions are met:
The individual is at least 18 years old.
The individual received SSI benefits because of blindness or a disability.
The individual became disabled or blind before age 22.
The individual lost SSI on or after July 1, 1987, because he or she:
Became eligible for DAC Title II Social Security benefits under child's insurance benefits.
Received an increase in DAC Title II Social Security benefits.
When the DAC criteria is met and the individual would be eligible for SSI benefits if the amount of the first Title II Social Security entitlement or an increase in the Social Security DAC benefit were not counted, then the individual is eligible for MA.
The CAO may be notified that an individual may qualify for DAC benefits by the following:
Automated CIS opening of NMP.
When SSI is stopped for a DAC, CIS automatically closes the A, J, or M budget and opens an NMP budget (PA, PJ, or PM with program status code 81).
The CAO will receive a weekly DAC Automated Openings report. The CAO must review cases for continued MA within three months.
The supervisor must review the budget if the three-month eligibility review results in closing MA.
DAC exception report.
Designated closings on SSI budgets will not be processed under any of the following conditions:
When there is an individual who is under 18 years of age.
When the CIS individual number and record number are not connected to the same SSN as the SSN on IEVS (Demographic Mismatch).
When the A, J, or M budget is closed in CIS.
When the individual is opened in a category other than A, J, or M in CIS.
IEVS disposition reason code.
In SDX payment status codes generate a disposition reason code alert that must be reviewed and cleared by the CAO worker. The CAO may need to contact the local Social Security office to determine the individual’s eligibility for continuing MA benefits.
NOTE: See Section 387.53, End of SSI MA Benefits, for instructions on reviewing eligibility.
The CAO must complete the following steps for the income review:
1. Determine NMP eligibility by using the gross amount of the Title II Social Security benefit before the loss of SSI.
NOTE: The amount of the Title II Social Security benefit may be zero. Spousal income must be counted. The only income that is not counted is the DAC Title II benefit.
Reminder: In some cases, the Title II Social Security benefit amount is increased and there is a delay in stopping SSI. Use the Title II Social Security amount that allowed SSI eligibility. Use the $20 disregard for either SSI or Title II.
2. Add any other income. If the result is less than the current SSI payment level, the individual is eligible on the basis of income.
NOTE: Other income includes, but is not limited to, Railroad Retirement, trust funds, Sheltered Workshop wages, and VA benefits.
Example: An individual has the following income before the Social Security Title II increase:
|
SSI |
$181.40 |
|
Title II |
$400.00 |
|
SSI payment level (2013) SSI payment level (2014) |
$732.10 $743.10 |
Title I Title II increases to $690.00. The individual has no other income. He or she continues to be eligible for MA. Use the Social Security Title II amount of $400.00 to decide on eligibility.
Income determination after the Social Security Title II increase is counted as follows:
|
Title II (used to decide on eligibility) |
$400.00 |
|
Other income |
$0.00 |
|
SSI payment level (2013) SSI payment level (2014) |
$732.10 $743.10 |
The individual's income is below the SSI payment level.
3. Determine whether the individual’s resources are less than the SSI resource limit.
4. Approve or continue MA in the correct NMP category (PA, PJ, or PM) with program status code 81.
NOTE: Disabled Adult Children are eligible for Buy-In if they get Medicare. A DAC in an HCBS program should remain in category PJ with program status code 81. The HCBS code must be entered for the type of waiver.
Important: The eligibility review does not require a face-to-face interview. The CAO must use the information in IEVS, CIS, and the case record to determine eligibility.
A PA 600 or PA 600R is not needed for the eligibility review. When more information is needed to complete the review, the CAO may use a PA 600 or PA 600R to get the information.
NOTE: Any future increases in DAC Social Security Title II benefits are not counted as income.
Special SSI Recipient status is given to a disabled or blind individual who is not eligible for SSI because of his or her earnings from employment. The Social Security Administration makes the decision on Special SSI Recipient status. The individual remains eligible for NMP and Buy-In.
Individuals who are given Special SSI Recipient status must be treated as full SSI recipients (A/J/M) when determining eligibility for other household members for NMP or MNO programs. These individuals and their income and resources are, therefore, excluded from the decision.
The CAO will get an IEVS Exchange #6 disposition reason alert letting it know of Special SSI Recipient status.
Important: The MA eligibility code on IEVS will be “C.” This code identifies federally run MA coverage. MA is continued no matter what the payment status code is.
When it gets an IEVS alert about Special SSI Recipient status, the CAO will:
1. Stop MA in the SSI category.
2. Open MA in the right NMP SSI-related category (PJ or PM) effective the day after the SSI budget is closed.
NOTE: An application is not required. A renewal is not required.
3. Send the individual a notice of eligibility.
4. Do not close the NMP budget until SSA lets the CAO know on IEVS that Special SSI Recipient status has ended.
Certain disabled widows and widowers who lost SSI because of Social Security Title II RSDI benefits continue to be eligible for MA. When deciding whether these individuals are eligible for MA, the CAO must consider them to be recipients of SSI benefits.
To qualify as a disabled widow or widower, an individual must meet all of the following conditions:
The individual is at least 50 years old and under 65 years old.
The individual must get widow's or widower's RSDI benefits.
The individual cannot get Medicare Part A benefits.
The individual lost or was denied SSI benefits because he or she received widow’s or widower’s Social Security Title II benefits.
The individual’s resources are within the SSI resource limit.
When Social Security Title II benefits are not counted, the individual’s income is less than the SSI payment level.
NOTE: The law providing MA coverage for disabled widows or widowers who lose SSI (42 U.S.C. 1383c(d)) specifies that Medicaid coverage applies if the widow or widower is eligible for Social Security benefits under 42 U.S.C. 402(e) or (f). One of the requirements under those sections is that the disability must have been approved within 84 months (seven years) of one of the following:
1. The spouse's death.
2. The last month in which they were eligible for mother's or father's survivor benefits.
3. The last month in which they were previously determined ineligible for Widow(er)'s coverage due to the end of their disability.
SSA contacts these individuals and lets them know by letter about their possible MA eligibility. SSA tells these individuals to contact the CAO to apply for MA.
The following information will be on the IEVS Exchange #6 record:
MA eligibility code W
Payment status code N01
New right to get Title II Social Security benefits, or an increase in those benefits
When an individual who may be eligible contacts the CAO, the CAO will review the individual’s case and decide whether he or she can continue to receive MA. The CAO will:
1. Decide whether the individual is eligible under the above conditions and the rules for SSI-related NMP.
2. If the individual is eligible, approve benefits in category PJ, and set alerts for future actions.
3. Put “disabled widow” or “disabled widower” in the CIS case comments.
4. When the individual becomes eligible for Medicare Part A, review the case for continued MA under PH, NMP, or MNO.
NOTE: See Section 387.53, End of SSI MA Benefits, for more information.
Under the Balanced Budget Act (BBA) of 1997, a child is eligible for MA if:
He or she was getting SSI on August 22, 1996.
He or she lost SSI because the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 changed the SSI definition of disability for children.
Because of the PRWORA, children getting SSI benefits on August 22, 1996, were reviewed by the SSA for continuing SSI eligibility using the new definition of disability. SSI was stopped on or after July 1, 1997, for those children who did not meet the new definition.
A child who used to get SSI is eligible for continuing Medical Assistance under the rules of the BBA of 1997 if he or she meets all of the following conditions:
The child was eligible for SSI cash benefits on August 22, 1996.
The child’s SSI payment stopped on or after July 1, 1997.
SSI payments were stopped because the child did not meet the definition of disability under the PRWORA of 1996.
The child would have kept getting SSI benefits if the definition of disability had not changed.
The child is under 18 years of age.
NOTE: This group will age out by August 22, 2014. In August 2014, any children who meet this criteria will reach the age of 18. If a child is age 18 or older they will be evaluated for their disability the same way SSA would evaluate the disability for any adult. A child over 18 can apply for SSI for himself.
If a child meets all of the above conditions, the CAO will:
Continue MA for the child up to age 18.
NOTE: If family members are getting TANF or MA, add the child to the family budget. If the child is the only family member eligible for Medical Assistance, approve the child in category PJ with program status code 98.
Make a note in the case comments that the child is eligible for Medical Assistance because of the PRWORA 1996/BBA 1997 laws.
Create an alert for age 18.
No renewal for MA benefits is needed until the child is 18 years of age. When the child turns 18, the CAO must review the child for continued MA eligibility. The CAO will:
Contact the family to apply for SSI for the child.
NOTE: The Social Security Administration will use the adult disability definition and standards to decide on the child’s SSI eligibility.
Inform the family that Medical Assistance will continue while the child is being reviewed for SSI.
If the child is in category PJ with program status code 98, close the budget and open a new one in category PH with program status code 00, for presumptive eligibility.
Refer the child to the Disability Advocacy Program (DAP). Explain that the DAP worker will help the family apply for SSI benefits. (See the Supplemental Handbook Chapter 820, Disability Advocacy Program.)
If the child is not eligible for SSI, the CAO must do the following:
Review the case for NMP or MNO MA.
If the child is eligible for NMP or MNO MA, close the PH/00 budget and approve benefits in the right category.
If the child is not eligible for NMP or MNO MA, stop PH/00 benefits after sending proper notice.
Reminder: MAPPER UTIL 900, SSI kids, lists children in Pennsylvania who lost SSI benefits. Use this file to confirm continued MA eligibility. For children who lived in another state when SSI stopped, ask for proof from the family, or contact SSA.
Updated December 11, 2013, Replacing January 1, 2013