Medicaid Continuations Specific to SSICash Recipients Welcome Presenter

Medicaid Continuations (Specific to SSI-Cash Recipients)

Welcome • Presenter Barbara Mc. Ginnis Senior Medicaid Trainer at

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Review of Workbook Location Content Front Pocket Page 1 3 5 19 25 35 Back Pocket DOH Directives & 2016 Standards Chart Agenda Objectives Power. Point Presentation Medicaid Continuations Book Pages Sample SDX Reports Case Example Answers (no peeking)

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

Learning Objectives

How long have you been determining Medicaid eligibility? q Less than 1 year q 1 year to 2 years q 2 years to 5 years q 5 years to 10 years q 10+ years

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

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

Who is responsible for maintaining the SSI-Cash cases in your county? q All Medicaid eligibility workers q Designated eligibility worker q Supervisor q Clerical staff

How are you notified a SSI-Cash Medicaid case has been opened? q BENDEX Report q MABEL q SDX Report q WMS

How are you notified a SSI-Cash Medicaid case has been opened? Answer: SDX Report (Automated SDX-WMS Interface Report)

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

Sample SDX Report

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

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

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

The SDX Process Terminations • Medicaid case is closed only if a recipient dies or moves transfers 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)

Reviewing the Data

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

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

Stenson

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

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

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

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)

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

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

Pickle

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

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

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 both by the individual and/or by their spouse were disregarded

Pickle Calculations • Using the “Reduction Factors for Calculating Medicaid Eligibility Under the Pickle Amendment During 2016” chart, determine the amount of countable income

Pickle Budgeting • Calculate countable SSA income § MBL Unearned Income Source Code 48 - Net Social Security Benefit-Pickle • Include other countable income • Compare to SSI-C 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)

503 MA ONLY MMM c i P e l k REFERRED TO STATE FOR DETERMINATION R

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

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

Pickle Example, cont’d Currently receives: SSA Benefits $762/Mo Pension $260/Mo 2016 Pickle Reduction Factor July 1996 =. 641

Jan. 1996 – Dec. 1996 . 641

Pickle Example, cont’d Pickle Reduction Factor, cont’d: $762 multiplied by. 641= $488 (Pickle SSI-Cash rounded down) + 260 (Pension) $748 - $20 (Income Disregard) $728 Resources $500 (Checking Account) vs. $2000 (SSI-C Resource Level for 1) vs. $820 (2016 SSI-Cash Income Level)

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

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

Disable Adult Child (DAC)

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

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

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

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

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)

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

DAC Process Identify individual is 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

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

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

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

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 ($260) • Unearned Income Exemption § 15 ($105)

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

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 purposesrecipient also loses DAC status May be subject to a spenddown when DAC benefit has to be counted

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

1619(a) & (b)

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

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

1619(a) • Protects SSI-Cash and Medicaid eligibility for individuals whose earnings exceed 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)

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

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

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)

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

NON PAY N 27 b 9 1 6 1 REFERRED TO STATE FOR DETERMINATION R

Widow/Widower

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

Widow/Widower 1 st Disregard, cont’d. • Becomes ineligible for SSI-Cash or State Supplement Program Payment 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 payments if s/he were not receiving such benefits § Not entitled to Medicare Part A hospital benefits

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

Widow/Widower, cont’d • Payment Status Code (SDX field 217) § NO 1 • Medicaid Eligibility Code (SDX field 216) §W • Case Type (WMS) § 20 § NYC case type remains a 22 until the final determination • SSI Status (screen 2) § 5

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