1619b and "Deemed Eligible" Clients (after DAC, Pickle/COLA, Widower exclusion)

Revised May 13, 2013

1619B and "Deemed SSI eligible" clients

• SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion AND SSI was closed due to the receipt of DAC, COLA income) don’t pay service participation. They DO pay room and board in an ALF
• 1619b clients are considered the same as an “SSI client” SSI payments have stopped due to earnings. SDX coding indicates to continue Medicaid on SDX 1 in the Med Elig field. 1619b clients don’t pay service participation. They DO pay room and board in an ALF.

Deemed SSI eligible clients.  What does that mean?

Clients who have COUNTABLE income under the SSI standard after allowing the exclusion for Disabled Adult Child (DAC), Pickle/COLA,  Widow/Widowers AND their SSI was closed because of the receipt of the DAC/COLA/Widow(er) income. 

These exclusions are described in WAC 182-512-0880.  Clients continue to receive CN Medicaid as long as they meet resource criteria.

• Not every client receiving DAC or Widower income is eligible for this exclusion. 
• DAC clients with countable income under the SSI standards are often called "Protected DAC" individuals.
• DAC clients with countable income over the SSI standard are not "protected DAC".
• Deemed SSI eligible clients do NOT pay HCB Waiver service participation, they do pay room and board if living in an ALF. 
• Deemed SSI eligible clients DO participate toward the cost of care when living in a medical institution. 
• If countable income is over the SSI standard after the exclusion then all income is counted in post eligibility in determining participation including DAC income.

In other words, an individual who would be eligible for CN/S02 in ACES

A client who would otherwise qualify for S02/CN SSI related medicaid because their countable income is at or below the SSI standard does not participate towards personal care under the Waiver program.  (but they are responsible to pay room and board when living in an ALF). 

These clients do need to meet the same criteria for long-term care services as other Waiver clients and may be subject to transfer of asset penalties or excess home equity described in WAC 182-513-1350 

Let the SW/Case manager know if client would be eligible for a non institutional CN program so MPC can be considered.  MPC is considered a priority over the HCB Waiver program.

1619b status, what does it mean? 

SSI clients whose earnings put them over the SSI cash benefit standard but Social Security continues their SSI eligibility.  They are considered a SSI recipient and continue to send in reviews to Social Security.  The SDX indicates continued Medicaid when a client is 1619b.  1619b clients don’t pay service participation because they are considered to be an SSI client.  Follow the same instructions as SSI clients on COPES for 1619b clients.  Code SI on UNER to prevent an eligibility review from being generated for the L21.   Clients would pay the ADSA room and board amount if residing in an ALF.  Clients can have GROSS income over the SIL  and continue to receive HCB Waiver as long as Social Security maintains their 1619b status. 

What happens if a client loses their protected DAC status?

• ACES is programmed to do the COLA, DAC, Widower disregard correctly as long as the SSI end date and the correct coding is indicated on the bottom of the ACES UNER screen.
• If a client on MPC loses protected DAC status and it is because of earnings, refer to the HWD specialist for a determination.  Active HWD recipients can receive either MPC or HCB Waiver services if functionally eligible.  The case-manager makes the decision as to the type of services the client will receive. 
• If a client on MPC at home loses protected DAC status and it is not due to earnings, send a referral to the client case-manager to see if the client is functionally eligible for a HCB Waiver as the client is no longer eligible to receive a non-institutional CN program.  If the client is in a residential setting, consider eligibility for G03. 
• If a client on MPC loses protected DAC status and is no longer eligible for non institutional CN medicaid and is on DDD MPC services, request that the DDD case-manager coordinate a referral to HCS intake to look at  the COPES waiver.   (DDD may not have an available slot on the DDD Waiver).  It is the responsibility of the DDD case-manager to coordinate with HCS in this scenario.  Set a barcode tickler to check status in 30 days. 
• If a client on HCB Waiver loses protected DAC status, they may be responsible to pay participation toward the cost of care.  Once a client loses protected DAC status, all the income including the DAC income is counted in determining if there is client responsibility toward the cost of care.