Recipients of SSI are eligible for MA. Most SSI recipients are automatically approved for MA by the eCIS/SDX electronic interface. The CAO must review information received from SSA through the “8036 Pend” SDX file on Exchange 6 via an Exchange 6 hit or alert and take any needed 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 into Buy-In for payment of Medicare Part B premiums by DHS. SSI recipients who are disabled (category J or M) will get Medicare once they have received Social Security Disability Insurance (SSDI) for 24 months. SSA will send an alert to CMS to have them auto-accreted to Buy-in.
NOTE: The CAO must monitor that SSA has successfully enrolled the individual in Buy-in. If the individual has not been enrolled in Buy-in after three months of Medicare eligibility, the CAO will enroll the individual in Buy-in through the manual accrete process, found in Section 388.62, Manual Accrete Process.
If Buy-in is closed while an individual is getting SSI, SSA will not reopen the Buy-in. The CAO will need to reopen the Buy-in using the manual accrete process.
The CAO finds out about a person’s SSI eligibility when any of the following happens:
MA
is automatically
opened in category A, J, or M by eCIS
as a result of the SDX electronic interface. MA
is effective on the
date indicated
on the
“MA Eligibility
Begin” field
on the MA/FS tab on Exchange 6.
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 notice
of eligibility (PA
162 M.1, Appendix C, SSI
Form Letters and Notices).
The CAO receives an Exchange hit or alert or checks Exchange 6 SDX Information for SSI eligibility.
The
SSI recipient contacts the CAO and
provides verification
of their
eligibility
with an award letter or proof of SSI payment. If proof is not available,
the CAO must use Exchange 6 SDX
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 eCIS to find out whether the recipient is active in category A, J, or M.
Enter the required information into eCIS to authorize benefits in category, A, J, or M if the SSI recipient is not already approved for MA. Open MA effective the date indicated on the “MA Eligibility Begin” field on the MA/FS tab on the “8036 Pend” file on Exchange 6.
NOTE:
If needed information is not available, contact the individual.
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 remain open in category J, and the CAO must enter a program status code on eCIS 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 eCIS.
Send the individual a Notice of MA Eligibility for SSI Recipient (PA 162 M.1). This notice lets the SSI recipient know of their 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 eCIS.
Review
the case for MA eligibility for the retroactive
period under other MA categories,
if the individual indicates paid and/or unpaid medical bills in the
retroactive period.
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 the date
shown
on the
“MA Eligibility
Begin”
field
on the MA/FS tab on Exchange 6.
(See IEVS Exchange #6, SDX Information.) The eCIS
automated
SSI opening process
approves MA back to this date. When the CAO must enter the MA approval,
the CAO will authorize SSI MA coverage back to the “MA Eligibility
Begin” date indicated on the “8036 Pend” file on Exchange 6.
NOTE:
If the
date is before the date that eCIS
will allow the CAO to approve eligibility, the CAO must submit a ServiceNow
request under Standalone
à Retro MA Requests
for the eligibility periods older than 365 days
(See Appendix B, Retroactive Medicaid Eligibility Requests.) Send
the applicant a PA
162-M.1.
The notice must show the beginning date of SSI eligibility and
the date MA is approved. The notice lets the individual know that they
must
contact the CAO if they
have 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:
Inform the individual that they should notify the provider(s) of those medical services furnished on dates covered by the retroactive MA, ask the provider(s) to resubmit the claims for payment under MA and request the provider(s) reimburse the out-of-pocket costs paid by the individual.
Most of the time, the CAO will get an Exchange 6 hit or an 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, PH 95, MAWD, MAGI, NMP, and Medically Needy Only (MNO), before terminating the 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 eCIS.
If the case is a single-individual SSI and SNAP case, the SSI
MA budget and the SNAP budget are closed by eCIS,
and a confirming notice is automatically
sent.
No Exchange
6 hit or alert will be received.
The CAO must first review the person’s eligibility for continued MA in a “Special SSI MA” category. An individual may be eligible for a “Special SSI MA” category if they meet one of the conditions listed below:
The individual became ineligible for SSI because of the Social Security Title II RSDI cost-of-living adjustment (COLA) or the individual lost SSI entitlement when they started receiving RSDI and now would be eligible for SSI if the COLAs received since the SSI terminated were not counted. ( Section 387.61, Loss of SSI - Disregard of COLAs (Lynch v Rank, “Pickle” Cases).)
The individual is a Disabled Adult Child (DAC) who became ineligible for SSI because of the receipt of, or an increase in, Social Security Title II child’s 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 the receipt of Social Security Title II RSDI benefits of their deceased spouse. ( Section 387.64, Disabled widows and widowers.)
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 Exchange 6
indicates the end of SSI, the CAO must review the information in the case
record, Exchanges,
and eCIS
to determine whether the individual is eligible for MA. The CAO must determine
eligibility for
other MA categories, such as: Healthy Horizons, PH 95, MAWD,
MAGI, NMP, and
MNO before terminating
SSI MA coverage as
explained below.
NOTE: This also includes individuals who were eligible for continued MA benefits under one of the “Special SSI MA” categories and either SSA or the CAO has determined them to no longer be eligible for that “Special SSI MA” category. (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:
Conduct an ex parte review using information on the Exchanges, eCIS, and the case record.
Close the
SSI category and open benefits in the new MA category effective as
of the day after the SSI closing date if
the Exchanges, eCIS,
and the case record have enough information to determine eligibility
for ongoing MA. eCIS
will set the renewal date. Review the renewal date, and align it to other budgets
in the case, if applicable.
Send proper notices.
NOTE: If there is enough information to determine eligibility and approve benefits, no contact with the individual is needed.
Send a pending
verification form (PA 253) to the individual if more information is
needed to determine eligibility.
Contact
the individual by telephone too,
if possible. Let the individual know that more information is needed
to determine
their eligibility for Medical
Assistance.
.
NOTE: Make special efforts to help individuals with Limited English Proficiency (LEP) or with other language barriers or disabilities provide information. Work with social workers, family members, or other individuals to get the information.
Send a renewal form, if one is needed.
Ask the individual to complete and sign the form and return it to the CAO. Let the individual know that an eligibility review must be completed and the due date to return the form and information to the CAO.
Creation of the appropriate alerts and work item for the return of the form or other requested information will be done by eCIS.
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. eCIS
will set the renewal date. Review the renewal date and align it to
other budgets on the case,
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:
The CAO determines there is adequate information to evaluate continued MA eligibility based on information in the case record and electronic data sources and a review of them shows ineligibility.
Review of the application or renewal form information shows ineligibility.
The individual does not give information needed to determine their eligibility.
In all 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 May 14, 2024, Replacing February 14, 2012