Recipients of SSI are eligible for NMP MA. Most SSI recipients are automatically approved for MA by the CIS/SDX electronic interface. The CAO must review information received from SSA through IEVS Exchange #6, SDX Information and take the proper action on the MA benefits.
NOTE: SSI recipients will get the PA ACCESS card. An ACCESS card will be issued if the SSI recipient has not been given a card before. ( Chapter 380, Issuing the ACCESS Card.)
SSA is responsible for the enrollment of SSI recipients who are entitled to Medicare and Buy-In for payment of Medicare Part B premiums by DHS. SSI recipients who are disabled (category J or M) will get Medicare 24 months after the date the disability has been established by SSA. SSA will not enroll these individuals in Buy-In.
NOTE: To confirm Buy-In enrollment, the CAO must set an alert to check IEVS Exchange #7, Buy-In. The alert should be set for 27 months after the date of eligibility. If the individual is not enrolled in Buy-In, the CAO must complete a manual accrete action. (See IEVS Exchange #7, Buy-In.)
The CAO finds out about a person’s SSI eligibility when any of the following happens:
MA is opened in category A, J, or M by CIS as a result of the SDX electronic interface. MA is effective on the “MA DT” (MA date) shown on the SDX screen.
NOTE: When SSA decides that an individual is eligible for SSI, SSI payments begin the first day of the month following the month the SSI application is filed or the date the individual becomes eligible for SSI benefits. For example, the application is filed in July. SSA decides in December that the individual was eligible back to the application date. SSI payments begin in August. MA eligibility is effective as of August. ( Appendix D, Automated SSI Open Process.) The individual must get a PA 162 M.1 ( Appendix C, SSI Form Letters and Notices.)
The CAO gets an alert or checks IEVS Exchange #6, SDX Information for SSI eligibility.
The SSI recipient contacts the CAO and proves his or her eligibility with an award letter or proof of SSI payment. If proof is not available, the CAO must use IEVS Exchange #6 to confirm the individual’s SSI status and eligibility begin date.
NOTE: Applicants who have applied for MA but are getting SSI and MA in another state for the current month are eligible for MA in Pennsylvania as long as the individual meets the definition of a resident of Pennsylvania. ( Chapter 323, Residence.)
When the CAO finds out that an individual is receiving SSI benefits, it will:
Check CIS to find out whether the recipient is active in category A, J, or M.
If the SSI recipient is not already approved for MA, approve benefits in category A, J, or M by entering the required information into CIS. Open MA effective as of the “MA DT” (MA date) on the SDX screen of IEVS Exchange #6. Use the person’s home address if the SSI payment is a direct deposit.
NOTE: If needed information is not available, contact the person. An Application for Benefits (PA 600) is not needed.
Reminder: When a child is eligible for both SSI and foster care or adoption assistance, the budget must stay in category J, and the CAO must enter a program status code on CIS to show that the child is in foster care or adoption assistance. (See Chapter 305, Appendix C, Program Status Codes.)
NOTE: No renewal date is posted to CIS.
Send the recipient a Notice of MA Eligibility for SSI Recipient (PA 162 M.1). This notice lets the SSI recipient know of his or her eligibility for MA and gives instructions about turning in medical bills for services from as far back as the eligibility date. ( Appendix C, SSI Form Letters and Notices.)
NOTE: Notices of MA eligibility are automatically sent out for cases opened by CIS. A PA/FS 162 and a PA 162 M.1 are always sent for an SSI opening. ( Chapter 338.8, Corrective Action Payment/Reimbursement for Paid and Unpaid Medical Expenses.)
Review the case for MA eligibility for the retroactive period under other MA categories.
NOTE: The individual is not automatically eligible for MA before the effective date of the SSI payment. The SSI application serves as an application for MA, and the retroactive period is the same as for any other MA application. The CAO must decide on retroactive MA eligibility for these individuals just as it does for other MA applicants. The date of the SSI application is also considered the date of the MA application. The retroactive period goes back three months before the month of application and extends up to the effective date of SSI payment. ( Chapter 338, Section 338.3, Retroactive MA Eligibility.)
Sometimes an individual may be found eligible for SSI after a long appeal process. MA coverage dates back to the date that the individual was eligible to get an SSI payment, which is shown as “MA DT” (MA date) on the SDX screen. (See IEVS Exchange #6, SDX Information.) The CIS process approves MA back to this date. When the CAO worker must enter the MA approval, the CAO will authorize SSI MA coverage back to the 365-days-plus-120 limit allowed by CIS.
NOTE: If the date is before the date that CIS will allow the CAO to approve eligibility, the CAO must use forms on the OIM Intranet to approve MA back to the date of eligibility. (See Appendix B, Retroactive Medicaid Eligibility Requests.) Send the applicant a PA 162-M.
The notice must show the beginning date of SSI eligibility and the date MA is approved. The notice lets the individual know that he or she must contact the CAO if he or she has paid or unpaid medical bills for the period that was not covered by MA. (Chapter 338, Section 338.8, Corrective Action Payment/Reimbursement for Paid and Unpaid Medical Expenses.)
If the individual has paid medical bills during this period, the CAO must:
Let the individual know that he or she may be paid back at a later date and that he or she will be contacted.
Tell the individual to keep all receipts.
Keep a log of SSI recipients with paid medical bills.
The CAO will get an IEVS Exchange #6 alert when an individual becomes ineligible for SSI. The CAO must review the individual's eligibility for all other MA benefits, such as Healthy Horizons, NMP, and Medically Needy Only (MNO), and for stopping SSI MA coverage.
Important: The SSI MA must remain open until the eligibility review for other MA benefits is completed.
If SSI benefits stop because of the death of a recipient, the SSI MA case is closed by CIS. If the case is a single-individual SSI and SNAP case, the SSI MA budget and the SNAP budget are closed by CIS, and a confirming notice is sent by CIS.
The CAO must first review the person’s eligibility for continued NMP under one the following special situations:
The individual became ineligible for SSI because of the Social Security Title II RSDI cost-of-living adjustment (COLA). ( Section 387.61, Loss of SSI - Disregard of COLAs (Lynch v Rank, “Pickle” Cases).)
The individual is a Disabled Adult Child who became ineligible for SSI because of an increase in Social Security Title II RSDI benefits. ( Section 387.62, Title II—Social Security Disabled Adult Child (DAC) benefits.)
The individual is ineligible for SSI cash payments because of earnings from employment but qualifies for Special SSI Recipient Status. ( Section 387.63, Disabled—Employment.)
The individual is a disabled widow or widower who lost SSI because of an increase in Social Security Title II RSDI benefits because of a change in the way that a widow's or widower's RSDI is computed. ( Section 387.64, Disabled widows and widowers.)
The individual is a child with disabilities who lost SSI because of the change in the SSI disability definition for children enacted by the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of August 22, 1996 (P.L. 104-193). These children continue to be eligible for MA up to age 18 because of the Balanced Budget Act of 1997 of August 5, 1997 (P.L. 105-33). (See Section 387.65, MA-eligible disabled children under the Balanced Budget Act (BBA) of 1997.)
NOTE: The MA eligibility codes, SDX Payment Status Codes, and Disposition Reason Codes may give information on a person’s eligibility for MA. (See Section 387.4, SSI—State Data Exchange (SDX) System).
If none of the above situations applies when IEVS Exchange #6 indicates the end of SSI, the CAO must review the information in the case record, IEVS, and CIS to determine whether the individual is eligible for MA. The CAO must determine eligibility for Healthy Horizons first, for NMP next, and for MNO last.
The CAO must review a case for continued MA eligibility, approve Healthy Horizons, NMP, or MNO, and stop SSI MA as follows:
NOTE: This includes recipients who are eligible for continued NMP benefits because of special situations. (See Section 387.6, Extended NMP—Special Situations.)
Continue MA in the SSI category.
NOTE: Do not send an advance notice to close MA benefits until the following steps are completed:
Review information on IEVS, CIS, and the case record.
If IEVS, CIS, and the case record have enough information to determine eligibility for other MA benefits, close the SSI category and open benefits in the new category effective as of the day after the SSI closing date. CIS will set the renewal date. Review the renewal date, and change it if needed to. Send proper notices.
NOTE: If there is enough information to determine eligibility and approve benefits, no contact with recipient is needed.
If more information is needed to determine eligibility, contact the individual by telephone, if possible, or by letter. Let the individual know that more information is needed to determine his or her eligibility.
NOTE: Make special efforts to help individuals with language barriers or disabilities give information. Work with social workers, family members, or other individuals to get the information.
Send an application/renewal form, if one is needed.
NOTE: Whether to use a PA 600HC, PA 600R, or PA 600 depends on the type of benefit eligibility being looked at. See Chapter 304, Application and Chapter 376, Renewal for information on using the forms.
Ask the individual to sign the form and return it to the CAO. Let the individual know that an eligibility review must be completed and by what date the form and information must be returned to the CAO.
Create appropriate alerts for the return of the form or other requested information.
Review the information when it comes in. If the individual is eligible for other MA benefits, close the SSI category and open benefits in the new category effective as of the day after the SSI closing date. CIS will set the renewal date. Review the renewal date and change it if needed. Send the proper notices.
NOTE: Parental income must be reported and verified before MA can be approved for a PH95 child.
Stop MA in the SSI category only after:
Review of the application or renewal form information shows ineligibility.
The individual does not give information needed to determine his or her eligibility.
In either of these cases, send an Advance Notice to close the SSI category. The notice must state why SSI MA is being closed and why other benefits will not be approved (for example, the individual does not qualify under other MA conditions, or proof or other information was not given to the CAO).
Updated February 14, 2012, Replacing December 17, 2008