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Groups Deemed to be Receiving SSI for Medicaid Purposes

This topic provides an explanation of the four Medicaid eligibility groups for individuals who are deemed to be receiving Title XVI, Supplemental Security Income (SSI) benefits and State Supplementary Payments (SSP or OSS) for purposes of Medicaid eligibility.

Eligibility Groups

Each of the four groups deemed to be receiving SSI/SSP for purposes of Medicaid is described below.

Section 503 (Pickle Amendment Group):

An individual who would continue to be eligible for SSI/SSP benefits if the total amount of the Title II Cost-of-Living Adjustments (COLAs) received since losing SSI benefits when also receiving Title II (OASDI) benefits was deducted from income.

This means an individual who:

·               Is receiving Title II;

·               Lost SSI/SSP but would still be eligible for those benefits if the total amount of the Title II cost-of-living increases received since losing SSI/SSP benefits while also entitled to Title II benefits was deducted from income. Cost-of-living increases include the increases by the individual, spouse or financially responsible family member; and

·               Was eligible for and receiving SSI or a State supplement concurrently with Title II for at least one month after April 1, 1977.

The individual would not automatically receive continued coverage and must apply separately to receive that continued coverage.

Disabled Widow(er)s:

A widow(er) with a disability who has been continuously entitled to widow(er)s insurance based on disability since January, 1984 and who would continue to be eligible for SSI/SSP benefits but for a 1983 change in the Title II actuarial formula and who applied for Medicaid continuation under this section no later than July 1, 1988.

This group included widows or widowers and some unmarried, divorced spouses who:

·               Have a disability;

·               Were receiving SSI/SSP benefits in December, 1983 and lost SSI/SSP benefits in January 1984 due to a statutory elimination of an additional benefit reduction factor for widow(er)s before attainment of age 60 who have been continuously entitled to widow(er)s insurance based on disability since January 1984; and

·               Applied for benefits under this group no later than July 1, 1988; or the later date for 209(b) States established under the court order in Darling v. Bowen, 685 F.Supp.1125; and

·               Would continue to be eligible for SSI/SSP benefits if he or she had not received the increase in Title II benefits.

Disabled adult child:

An adult with a disability that began before age 22 who would continue to be eligible for SSI/SSP benefits but for the receipt or increase in Title II disabled adult child benefits.

This group includes an individual who was receiving SSI/SSP benefits and who meets the following:

·               Is over the age of 18;

·               Has blindness or a disability which began before the age of 22;

·               The individual is entitled to Title II benefits on a parent’s record due to the retirement, death or disability of a parent, and loses SSI/SSP due to receipt of that benefit or increases in that benefit; and

·               The individual would continue to be eligible for SSI/SSP in the absence of the Title II disabled adult child's benefit or such increases to that benefit.

The individual is notified in the SSI termination letter from the Social Security Administration that he or she may continue to be eligible for Medicaid coverage under this group. The individual should contact the Medicaid State agency for Medicaid continuation. Continued eligibility for the individual is not automatic in all cases.

Early Widow(er)s:

A widow(er) with a disability receiving widow(er)s benefits under Title II or who receives other Title II benefits but is eligible to receive Title II widow(er)s benefits and who would continue to be eligible for SSI/SSP benefits but for receiving early Title II widow(er)s benefits or an increase in those benefits and who is not yet eligible for Medicare Part A benefits.

This group includes widow(er)s and some surviving, divorced spouses who have a disability who were receiving SSI/SSP who:

·          Lost SSI/SSP benefits due to a mandatory application for and receipt of Title II benefits;

·          Are not yet eligible for Medicare Part A;

·          Are at least age 50, but have not yet attained age 65; and

·          Would continue to be eligible for SSI/SSP benefits if they were not receiving the Title II benefits.

The individual will be notified in the SSI termination letter from the Social Security Administration that he or she may continue to be eligible for Medicaid coverage under this group. The individual should contact the Medicaid State agency for continued Medicaid coverage. Continued eligibility for the individual is not automatic in all cases.

Clarification Of Terms And Scope

The terms "SSI program" and "SSI benefits" are used throughout this topic. That means the individual may either be receiving cash benefits under Title XVI (SSI) or be a 1619(b) participant (receiving Medicaid benefits, but not cash benefits). Individuals in either of these categories are considered to be receiving SSI benefits and are eligible to participate in the groups described in this topic.

State Supplementary Payment (SSP) means individuals who receive a cash benefit in addition to a Federal SSI benefit which can be administered by the State or by the Federal governments; see §1905(j) of the Social Security Act which defines SSP for purposes of Medicaid. In some cases, individuals may receive only the State Supplementary Payments (SSP). In both cases, these individuals are eligible for the Medicaid continuation groups described in this topic, and the State should have eligibility processes to assess whether these individuals would be eligible for one of these groups.

State Medicaid Eligibility Categories

In providing Medicaid to individuals who are receiving or deemed to be receiving SSI, States fall into one of three general categories:

1634(a) States

This terminology, referring to Section 1634 of the Social Security Act, means States have a contract with the Social Security Administration to determine eligibility for Medicaid at the same time a determination is made for receipt of SSI benefits. These 32 States and the District of Columbia also use the same Medicaid eligibility criteria for determining for their aged, blind and disabled SSI recipients as are used for the SSI program.

SSI-criteria States

This means States that use the same Medicaid eligibility criteria for their aged, blind, and disabled SSI recipients as are used for the SSI program, but require that these individuals apply to the State separately from their application for SSI to determine their Medicaid eligibility based upon that application. There are 7 States and the Commonwealth of Northern Mariana Islands that are categorized as SSI-criteria States.

209(b) States

This means States that use more restrictive Medicaid eligibility criteria for their aged, blind and disabled recipients than are used in the SSI program in one or more eligibility areas. There are 11 States that are categorized as 209(b) States.

Medicaid Determinations For States That Use SSI Criteria

If the agency uses SSI criteria in determining eligibility (i.e.1634 and SSI-criteria States), it must disregard all of the Title II benefit (for the Disabled Adult Children and Early Widow(er)s groups only) or the relevant increases in that benefit (for all four groups) provided the individual also meets the other Medicaid eligibility criteria for SSI.

Medicaid Determinations For States That Use More Restrictive Criteria Than SSI

If the agency uses more restrictive eligibility requirements than are used by the SSI program (i.e. 209(b) States), it must provide Medicaid to individuals discussed in this topic using the same eligibility criteria basis as Medicaid is provided to individuals who receive SSI benefits. For all groups discussed in this topic except Disabled Widow(er)s, the State has the option of disregarding part, all, or none of the Title II benefit or increases in that benefit that make the individual ineligible provided that the same amount is disregarded for all members of the group.

For individuals eligible for the Disabled Widow(er)s group, the State must disregard all of the Title II benefit or increases in that benefit that would make the individual ineligible.

If an individual incurs enough medical expenses to reduce his or her income to the State’s financial eligibility standard for categorically needy, the agency must cover the individual as categorically needy.

See also

Medicaid - Overview

Medicare - Overview

Supplemental Security Income

Disability Insurance - SSDI (Title II)

Medicaid Eligibility - States with own Criteria

Source

Information for this topic was drawn from the CMS website (requires Adobe Acrobat) at:
http://www.cms.gov/medicaid/eligibility/ssideem.pdf

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