Medicaid Continuations Specific to Former SSICash Recipients 1

Medicaid Continuations Specific to Former SSI-Cash Recipients 1

Logistics • Panel • Typed questions • Raise your hand 2

Logistics • Audio tab • Telephone OR mic and speakers Technical Difficulties? Call 1 -888 -259 -8414 3

Important Notice • This Goto. Webinar/Goto. Meeting service includes a feature that allows audio and any documents and other materials exchanged or viewed during the session to be recorded. • By joining this session, you automatically consent to such recordings. • Please note that any such recordings may be subject to discovery in the event of litigation. 4

Welcome • Presenter Barbara Mc. Ginnis Senior Medicaid Trainer at 5

Review of Workbook Location Front Pocket Page 1 2 3 21 27 41 49 Back Pocket Content DOH Directives & 2016 Standards Chart Agenda Objectives Power. Point Presentation Medicaid Continuations Book Pages Sample SDX Reports Case Examples SDX Manual Excerpt Case Example Answers (no peeking) 6

Agenda • State Data Exchange (SDX) Report • Medicaid Continuations for: – Stenson – Pickle (formerly 503 cases) – Disabled Adult Children (DAC) – 1619(a) & (b) – Widow/Widowers 7

Learning Objectives 8

POLLING QUESTION How long have you been determining MA eligibility? q Less than 1 year q 1 to 5 years q 5+ years 9

Medicaid Continuations • Due to various federal legislation and court decisions, certain disabled individuals are entitled to continued Medicaid eligibility after they have lost their SSI-Cash benefit 10

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POLLING QUESTION Have you processed any Medicaid Continuation cases? q. Yes q No 12

State Data Exchange (SDX) Report • The State Data Exchange (SDX) provides detailed information about benefits received by SSI-Cash applicants/recipients • It is used to verify SSI-Cash benefits in determining eligibility for various public assistance programs 13

Page 55 A S P M E L D S X E R O P T R 14

Auto-SDX Process Applications Auto-SDX checks WMS for “Current Medicaid Eligibility” Match based on SSN, Sex, and DOB Match Found No Match Found Partial Match (Ex. SSN match, but not DOB) Update record to MA-SSI case automatically opened by SDX in the DFR Exception reported to LDSS on Transaction Control Report 15

Auto-SDX Process Applications, cont’d. • Auto-SDX spawns SNAP case based on NYSNIP calculations 16

The SDX Process Changes • Auto-SDX monitors 33 fields for changes • SSI payment status • Address • Representative Payee • Disability Dates • Unearned Income Date and Type • Etc. • Based on the fields that change, Auto-SDX will update WMS as appropriate 17

The SDX Process Terminations • Medicaid case is closed only if a recipient dies or moves out of state • Case is given a 35 day clockdown • All other SSI-Cash terminations result in Medicaid remaining open for 1 year in order for the LDSS to determine Medicaid eligibility – (Stenson v Blum, 1980) 18

Reviewing the Data 19

Page 55 A S P M E L D S X E R O P T R 20

POLLING QUESTION How are you notified that a Medicaid SSICash case has been opened? q BENDEX Report q MABEL q SDX Report q WMS 21

POLLING ANSWER How are you notified that a Medicaid SSICash case has been opened? SDX Report (Automated SDX-WMS Interface Report) 22

Questions? Technical Difficulties? Call 1 -888 -259 -8414 23

Medicaid Continuation Cases • • • Stenson Pickle (formerly 503 cases) Disabled Adult Children (DAC) 1619(a) & (b) Widow/Widowers 24

POLLING QUESTION What percentage of your caseload contains Medicaid Continuation cases? q q 0% - 25% - 50% - 75% - 100% 25

Stenson 26

Stenson v. Blum • Alleged Medicaid benefits were terminated improperly when eligibility for SSI-Cash was lost • Court required: – Changes to the Medicaid eligibility determination and notification for those individuals whose SSI-Cash benefits are terminated for reasons other than death – Notification Procedures • 80 ADM – 19 27

80 ADM-19 • Implementation of U. S. District Court Decision: Stenson, et al v. Blum Front Pocket 28

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Stenson Procedures WMS SDX received showing SSI-Cash ineligibility Case Type changed from 22 (SSI) to 20 Determination (Medicaid only) Determine continued Reason Code 988 Medicaid eligibility & Medicaid coverage date send required notice shortened from 12/31/49 to one year from transaction date 31

Check for Understanding Page xx 32

Check for Understanding What benefit must an individual lose to be eligible for a Medicaid Continuation determination? SSI-Cash Benefit 33

Check for Understanding What main document will you use to determine eligibility for one of the Medicaid Continuation programs? SDX Report (Automated SDX-WMS Interface Report) 34

Check for Understanding Other than individuals who die or move out of state, WMS will shorten the authorization date to what date in order for the LDSS to determine continued Medicaid eligibility? 1 year from the transaction date 35

Check for Understanding The Stenson policy requires a determination of continued Medicaid eligibility. True or False? True 36

Questions? Technical Difficulties? Call 1 -888 -259 -8414 37

Pickle 38

Pickle Cases (503) Lynch v. Rank • Section 503 of Public Law 94 -566 also referred to as the Pickle Amendment • Pickle Reference Documents – 85 ADM - 35 – 87 ADM – 27 • For reference only, not included in training materials 39

Pickle Criteria Lynch v. Rank • At some time on or after April 1977 was eligible for and/or received SSA benefits and SSI-Cash at the same time • Lost SSI-Cash eligibility but currently eligible for and receiving SSA benefits 40

Pickle Criteria, cont’d. Lynch v. Rank • Received SSA COLA’s since the last month in which they received both SSA and SSI-Cash benefits • Would still be eligible for SSI-Cash if such COLA’s received by the individual and/or their spouse were disregarded 41

15 INF-10 • Social Security Administration (SSA) Costof-Living (COLA) for January 2016 and updated SSI and SSP Benefit Levels Chart Front Pocket 42

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15 INF-10 – Last page 44

Pickle Calculations • To determine the countable income amount, use the "Reduction Factors for Calculating Medicaid Eligibility Under the Pickle Amendment During 2016" chart Front Pocket 45

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Pickle Budgeting Calculate countable SSA income § MBL Unearned Income Source Code 48 - Net Social Security Benefit-Pickle Include other countable income Compare to SSI-Cash income/resource standards § Done offline Cannot spenddown based on Pickle calculations

Identifying Pickle Cases • SDX – Payment Status (217) - MMM – Medicaid Eligibility (216) - R • WMS – Case Type - 20 (Screen 1) – SSI Status Code - 5 (Screen 2) 48

Page 29 503 MA ONLY MM I P K C E L REFERRED TO STATE FOR DETERMINATION R

Exceptions to Eligibility Individuals who appear otherwise categorically and/or financially eligible under the Pickle Amendment would NOT be eligible if: Currently have a recoupment SSI is in the Are closed taken against process of because they Received SSI them by SSI making a moved out of -Cash in error for money recoupment NYS incorrectly paid 50

Pickle Example Mrs. Johnson received SSA and SSI-Cash from 1992 – July 1996 She began receiving a pension July 1996 combined with SSA income resulted in loss of her SSI-Cash benefit Mrs. Johnson reports her only resource is a checking account of $500 51

Pickle Example, cont’d. Mrs. Johnson’s Monthly Income: SSA Benefits $762 Pension 260 52

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Jan. 1996 – Dec. 1996 . 641 54

Pickle Example, cont’d. Pickle Reduction Factor, cont’d: SSA Income Pickle Reduction Factor Countable SSA Income Pension SSI-R Income Disregard Total Countable Income $ 762 x. 641 488 (Rounded down) + 260 748 - 20 $ 728 vs. $820 (2016 SSI-Cash Income Level) Resources Checking Account $500 vs. SSI-C Resource Level for (1) $2000 55

Determine Pickle/Medicaid Eligibility • Budget Type § 04 • Unearned Income Codes § 48 – Social Security Benefit – Pickle ($488) § 39 – Retirement Benefit – Pensions ($260) 56

Chronic Care Budgeting • Pickle disregard is not allowed when determining income available for the cost of care under Chronic Care budgeting 57

Case Example 1 Donald Quimby Page 41 58

Case Example 1 In January 2008 Mr. Quimby lost his SSI Cash eligibility due to the cost of living increase in his Social Security Disability benefit. The LDSS received an SDX report indicating this change. The last time Mr. Quimby received SSI-Cash and SSD at the same time was December 2007. Using the 2008 SDX determine the following information: What was Mr. Quimby’s Social Security Disability benefit amount in January 2008? Answer: Mr. Quimby was receiving $648 in January 2008. 59

Case Example 1, cont’d. What was Mr. Quimby’s Social Security Disability benefit amount in December 2007? Answer: Mr. Quimby was receiving $539 in December 2007. Was Mr. Quimby receiving other unearned income, if so what type of unearned income, when did it start and how much does he receive? Answer: Mr. Quimby began receiving a VA benefit in Jan. 2006. The amount of this benefit was $100. 60

Case Example 1, cont’d. Was Mr. Quimby previously eligible for Medicaid? If so, when did his Medicaid eligibility start? Answer: Mr. Quimby was first eligible for Medicaid on 07/01/1978. What, if any, resources did Mr. Quimby report? Answer: The only resource reported on the SDX is a home, which is indicated to be his primary place of residence (homestead). 61

Case Example 1, cont’d. At that time, did Mr. Quimby have a spouse or anyone else that he is living with that would be considered in determining his eligibility? Answer: In field (42) it states that Mr. Quimby is single, widowed or divorced. What is Mr. Quimby’s alien status? Answer: Mr. Quimby is a proven U. S. born citizen (41) 62

Case Example 1, cont’d. In 2008 what Medicaid Continuation Category would Mr. Quimby be considered for? Answer: Mr. Quimby was previously eligible for SSI Cash and Social Security Disability concurrently. In January 2008 he did not receive an SSI-Cash check but continued to receive SSD. He would meet the non-financial criteria for the Pickle Continuation. Field (217) always gives the payment status of “ 503 MA ONLY MMM” which is also another indicator that Mr. Quimby was potentially Pickle eligible. 63

Case Example 1, cont’d. Mr. Quimby returned his renewal packet (2016). He reports receiving $725 in Social Security Disability and still receives $100 in a VA pension. Everything else on Mr. Quimby’s case remains the same. Would he be eligible for Medicaid? Answer: Upon renewal in 2016 Mr. Quimby’s ongoing eligibility needs to be determined. He currently receives $725 in Social Security along with a VA benefit of $100. $725 x. 849 = $615 + $100 = $715 - $20 = $695 vs. $820 (2016 SSI-C Level) 64

Questions? Technical Difficulties? Call 1 -888 -259 -8414 65

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Disabled Adult Child (DAC) 67

Disabled Adult Child (DAC) • DAC benefits are received upon the disability, retirement, or death of a parent • DAC Reference Documents – 95 ADM -11 – 92 LCM - 41 – 95 LCM – 28 • For reference only, not included in training materials 68

DAC Criteria • Must be at least 18 years old • Was receiving SSI-Cash benefits because of blindness/disability • Became certified blind/disabled before age 22 • Lost their SSI-Cash benefit on or after 7/1/87 due to initial entitlement or increase in DAC benefit 69

DAC Budgeting • If loss of SSI-Cash benefit is due to: – Initial entitlement of DAC benefit • Disregard the entire amount of DAC benefit, including subsequent increases – Increase in DAC benefit • The DAC benefit counted is the amount received in the month prior to SSI-Cash termination 70

DAC Budgeting, cont’d. • If the individual would otherwise be eligible for SSI-Cash when the appropriate DAC benefit is disregarded, the individual remains eligible for Medicaid 71

Identifying DAC Cases • SDX – Payment Status Code (217) - N 01 – MA Eligibility Code (216) - D • WMS – Case Type – 20 (Screen 1) – SSI Status – 5 (Screen 2) 72

Page 31 NON PAY N 01 D C A STATE DETERMINATION DISABLED ADULT CHILD D 73

DAC Process Identify individual is a DAC using SDX Determine if SSI -Cash was lost due to new or increased DAC benefit Determine Medicaid eligibility allowing DAC disregard Include all other countable income in the Medicaid eligibility determination 74

DAC Budgeting • Expanded Eligibility Code (EEC) § E – Disabled Adult Child (DAC) • Unearned Income Code § 47 – Social Security Benefit (DAC) • Unearned Income Exemption § 15 - Receipt/Increase in SSICB resulting in SSI Ineligibility 75

DAC Example A 45 year old woman receives $624 per month in DAC benefits She also receives $150 pension In April 2016 her DAC benefits are increased to $729 per month and SSA terminates her SSI-Cash benefits 76

Calculate Increase to be Disregarded for DAC Current DAC benefit $729 Previous DAC benefit - 624 DAC disregard 105 77

Determine DAC/Medicaid Eligibility • Budget Type § 04 • Expanded Eligibility Code (EEC) § E – Disabled Adult Child (DAC) • Unearned Income Codes § 47 – Social Security Benefit – DAC ($729) § 39 – Retirement Benefit – Pensions ($150) • Unearned Income Exemption § 15 ($105) 78

MBL Eligibility Calculation for DAC $729 Current DAC Benefit -105 DAC Disregard 624 +150 Pension 774 - 20 Income Disregard 754 vs $820 (2016 SSI-Cash Level) 79

DAC Additional Information When income/resources (other than DAC benefit) increase resulting in loss of SSI-Cash, individual is not eligible for DAC budgeting for Medicaid purposes May be subject to a spenddown when DAC benefit has to be counted 80

DAC Additional Information, cont’d. If income/resources are again reduced to SSICash levels, except for increases in or entitlement to DAC benefit, the individual may again be Medicaid eligible under the DAC provision DAC benefits are not disregarded when determining income available for the cost of care under Chronic Care budgeting 81

Case Example 2 Michael Gibson Page 45 82

Questions? Technical Difficulties? Call 1 -888 -259 -8414 83

1619(a) & (b) 84

1619 • SSA is responsible for the initial eligibility determination and subsequent renewals • Also known as Qualified Severely Impaired Individuals (QSI) 85

1619, cont’d. • LDSS is responsible for identification of these individuals through SDX and authorizing Medical Assistance based on SSA data • 1619 Reference Documents – 87 ADM – 44 • For reference only, not included in training materials 86

1619(a) • Protects SSI-Cash and Medicaid eligibility for individuals whose earnings exceed the SGA (Substantial Gainful Activity) • Districts have limited involvement with the 1619(a) eligible cases as they remain – CT 22 – SDX - In Pay Status (CO 1) 87

1619(b) • Protects Medicaid eligibility for individuals who lose SSI-Cash due to earned income • Medicaid continues until a “threshold” amount is reached 88

1619(b), cont’d. • SSA calculates the value of Medicaid and SSI-Cash for each state • This threshold amount of gross income is used by SSA to determine eligibility for 1619(b) • 2016 threshold equals $43, 583 89

Identifying 1619(b) Cases • SDX § Payment Status Code (217) - E 01 or N 01 § MA Eligibility Code (216) - C • WMS § Case Type – 22 (Screen 1) § SSI Status – 4 (Screen 2) 90

Page 31 NON PAY N 01 E 01 1 1 6 b 9 CONTINUED W/O REGARD FOR PAYMENT STATUS C 91

Widow/Widower 92

Widow/Widower 1 st Disregard • 60 years of age or older • Applies for and receives an early widow(er)s’ insurance benefit, or other benefits under section 202 of the Social Security Act, but is eligible to receive a widow(er)s’ benefit 93

Widow/Widower 1 st Disregard, cont’d. • Becomes ineligible for SSI-Cash or State Supplement Program as a result of receiving such benefits • Will remain eligible for Medicaid as long as the following criteria are met: – Would be eligible for SSI-Cash payments or State Supplement Program if s/he were not receiving such benefits – Not entitled to Medicare Part A hospital 94 benefits

Widow/Widower 2 nd Disregard • Certified disabled widow/widower who lost SSI-Cash and Medicaid benefits due to an actuarial adjustment in 1983 • Contact your local district liaison 95

Identifying Widow/Widower Cases • SDX § Payment Status Code (217) - N 01 § MA Eligibility Code (216) - W • WMS § Case Type – 20 (Screen 1) § SSI Status – 5 (Screen 2) 96

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Questions? Technical Difficulties? Call 1 -888 -259 -8414 99

Summary • State Data Exchange (SDX) Report • Medicaid Continuations for: § § § Stenson Pickle (formerly 503 cases) Disabled Adult Children (DAC) 1619(a) & (b) Widow/Widowers 100