387.5 MA Coverage for SSI Recipients

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.)

387.51 Approving MA

The CAO finds out about a person’s SSI eligibility when any of the following happens:

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.)

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:

      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.


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.)


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.)

387.52 Delayed SSI Coverage

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:

387.53 End of SSI MA Benefits

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:

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:      

NOTE:  If there is enough information to determine eligibility and approve benefits, no contact with recipient is needed.

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.

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.

 NOTE:  Parental income must be reported and verified before MA can be approved for a PH95 child.

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