Special Medicaid Beneficiaries. Lucy Miller WIPA NTC September 2009. Some Medicaid Basics. Whatever the program, people receive Medicaid coverage because they meet two criteria: They belong to a specific covered group; and
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Whatever the program, people receive Medicaid coverage because they meet two criteria:
Former SSI recipients who lose eligibility for cash benefits …
When determining Medicaid eligibility for these special former SSI recipients, State Medicaid agencies must exclude that portion of the individual’s applicable title II disability benefit that caused ineligibility for SSI payments. That may be the entire payment, increases in the payment, or in the case of Pickle People - COLAs
The terms “SSI program” and “SSI benefits” mean the individual may either be receiving cash benefits under Title XVI (SSI) or be a 1619(b) participant who is receiving Medicaid benefits, but not SSI cash payments.
Individuals in either of these categories are considered to be receiving SSI benefits and are eligible to participate in the special Medicaid groups.
Allows individuals who receive SSDI and lose SSI entitlement for any reason to continue Medicaid if:
Casey was receiving SSDI in the amount of $656 with $1 of SSI in 2008. He was not working. Casey’s 2009 cost-of-living adjustment raised his benefit to $696. Since this amount is over the current FBR +$20 ($674 + $20 = $694) in 2009, Casey is no longer eligible for SSI.
What would happen to Casey’s Medicaid in this situation?
In Casey’s situation, the Medicaid agency must exclude the increase between $656 and $696 ($40) that caused Casey to lose his SSI benefit. Since Casey has no other income and resources meet the SSI limits, he is eligible for continued Medicaid under the Pickle Amendment
Section 1634 of the SS Act requires States to consider title II Childhood Disability Beneficiaries (CDBs) who lose SSI eligibility as if they were still SSI recipients for Medicaid purposes, so long as they would have remained otherwise eligible for SSI benefits but for their entitlement to (or increase in) CDB benefits
Lucy was receiving CDB payments based on the work record of her stepmother. While the stepmother was alive, Lucy received $500.00 per month. The stepmother died recently, however, and Lucy’s CDB benefit was raised to the survivor’s benefit level of $750.00
Will Lucy keep her Medicaid?
The State Medicaid Agency must exclude the $250.00 difference between what Lucy was receiving before her stepmother’s death, and what she currently receives. If Lucy has no other income and has resources under the SSI limit, she would be eligible for Medicaid. If she has other income, she may or may not be eligible for Medicaid, depending on the type and amount of the income.
Cindy is 20 and receives SSI. Her mother retired and applied for Social Security Retirement Insurance Benefits. Her mother had high earnings, and Cindy’s payment as a CDB based on her mother’s work will be $700.00 per month.
What might happen to Cindy’s Medicaid in this situation?
Since Cindy had no Childhood Disability Benefits before her mother retired, the state must exclude all of Cindy’s CDB benefits when determining her eligibility for Medicaid If Cindy has other income or countable resources it might affect her entitlement to Medicaid.
In 1991, The SS Act was amended so that any former SSI eligible widow(er) will be considered by the state to be an SSI recipient for Medicaid purposes who:
NOTE: When a former SSI recipient is found entitled to DWB benefits, all months on the SSI rolls at any time are credited concurrently against the 5-month disability waiting period and 24-month Medicare Qualifying Period. That means that Medicare coverage may begin with first month of DWB payments.
The state Medicaid agency’s ability to exclude DWB when determining entitlement to Medicaid ends with entitlement to Medicare Part A. At this point, be sure to check for QMB/SLMB eligibility!
All states must use the same income/resource eligibility rules for SSI Medicaid recipients and Special Medicaid Beneficiaries. Rules may differ from state to state (209b states in particular), but must be consistent between these programs. Know your state rules!
How much can a Special Medicaid Beneficiary earn without losing Medicaid?
Examples with other forms of unearned income and earned income
Individuals who lose Special Medicaid entitlement due to other income, may return to this status if income drops, and exclusion of appropriate title II would make the individual again eligible for Medicaid. This may occur at any time in the future.
Note: DWBs may not retain Special Medicaid status after Medicare coverage begins.
In order to correctly calculate Medicaid eligibility, the State must establish: