387.6 Extended NMP—Special Situations

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.

387.61 Loss of SSI—Disregard of Cost of Living Adjustments (COLAs) (Lynch v. Rank, “Pickle” Cases) (PJ 84, PA 84, PM 84)

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:

387.611 Pickle Amendment Access Through DocuShare or Management Reporting in the Enterprise Data Warehouse (EDW)

The Social Security Administration (SSA) has given DHS a file of 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 file might be eligible for NMP under  the Pickle amendment. The information is available for the CAO to review on DocuShare and in Management Reporting in the EDW. The file is updated annually. 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 termination date and Title II (RSDI) benefit amount at the time the individual lost SSI.

 

To access this file, you may open it one of two ways.

 

1) Access DocuShare; the folder “MAPPER PICKLE Report” is on the landing page under “Other Collections:” see the screenshot below.

 

OR

 

2) Sign into the EDW’s Management Reporting, using CWOPA credentials. The file is located under the following path: Public Folders>Income Maintenance>SSA Pickle Data Reporting Package. Once the package has been entered a landing page will be visible, the CAO can view or filter information using the individual’s claim account number, name and other search criteria (see below).  
 

To populate all individuals on the Pickle Report, do not select any filter criteria and click the “finish” button toward the bottom left-hand corner of the window.

 

 

387.612 Eligibility under the Pickle Amendment

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)

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:

Review the individual’s eligibility if a change takes place because of any of the following:

387.62 Title II—Social Security Disabled Adult Child (DAC) Benefits (PJ 81, PA 81, PM 81)

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:

 

A Disabled Adult Child is eligible for NMP if all of the following conditions are met:

 

The individual lost SSI on or after July 1, 1987, because he or she:

 

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:

   Designated closings on SSI budgets will not be processed under any of the following conditions:

   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 (2021)

SSI payment level (2020)

SSI payment level (2019)

$816.10

$805.10

$793.10

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 (2021)

SSI payment level (2020)

SSI payment level (2019)

$816.10

$805.10

$793.10

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.

387.63 Disabled—Employment (PJ 85, PA 85, PM 85)

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.

387.64 Disabled Widows and Widowers (PJ 83)

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:

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:

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.

 

387.65 MA-Eligible Disabled Children under the Balanced Budget Act (BBA) of 1997

Under the Balanced Budget Act (BBA) of 1997, a child is eligible for MA if:

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:

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:

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.

 

NOTE: The Social Security Administration will use the adult disability definition and standards to decide on the child’s SSI eligibility.

If the child is not eligible for SSI, the CAO must do the following:

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 February 1, 2021,  Replacing January 23, 2020