MEDICAL REDETERMINATION
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MEDICAL REDETERMINATION


Revised December 27, 2012



SSI REDETERMINATION

When a client loses eligibility for Supplemental Security Income (SSI) cash assistance, the department must redetermine their eligibility for Medicaid.  The State Data Exchange (SDX) interfaces with ACES and provides us with information regarding the termination or suspension of SSI cash assistance.  (The ACES automated redetermination process does not apply to any client where the SDX medical eligibility code shows as A, C, G, N, Q or Y on the SDX1 screen.  These clients are considered SSI cash recipients and remain eligible under the S01 medical coverage group).

When the medical eligibility code is 'R' (Referred to State), the ACES system takes the following steps, depending on whether the SSI is in non-pay status or is in suspended status.

Suspended Status

ACES checks the SDX to determine the client's payment status code.  If the code is a payment suspense code (S01, S04, S05, S06, S07, S08, S09 or S10) ACES waits and does not generate the 22-05 Redetermination letter and Alert 248 - SSI Terminated, Redetermine Medical Eligibility for 60 days.  Social Security uses the suspense codes when updating a client's address, changing a payee or budgeting fluctuating income and in many cases the SSI cash starts again within a short period of time.

If the client's status changes again from suspended status to non-pay status at any time during the 60 day wait period, the 22-05 Redetermination letter is generated, along with the 248 Alert.

If the client's status changes from suspended back to a pay status, then all tracking is stopped and no 22-05 Redetermination letter is sent. ACES automatically removes the SSI closure information from the bottom of the UNER screen when this happens. 

After 60 days, if the status on the SDX has not changed, ACES generates the 248 Alert and 22-05 Redetermination letter to the client.

Non-Pay Status

When the SSI closes for a client who is not in a suspended status with Social Security Administration, ACES populates the bottom of the UNER screen with the SSI closure date and generates the 22-05 Redetermination letter and Alert 248. 

Both suspended and terminated clients have 60 days from the review is sent to return the form.  At the end of 60 days, if the S01 AU is still active, ACES will check for 'Y' (Yes) in the ELIG RVW RCVD field on the MISC screen to indicate the review has been received.  A barcode to ACES interface automatically populates this field if an eligibility review form is received in the Document Management System (DMS).

If there is a 'Y' on the MISC screen, Alert 251-SSI TERM'D 60 DAYS AGO, COMPLETE MED REDETERMINATION generates and the AU remains active until the review is initiated in the system.

If there is not a 'Y' on the MISC screen, the S01, L01 or L21 AU's will automatically close with reason code 235 - Review Not Complete and ACES generates the correct termination letter allowing advance notice. At this point, the redetermination process is complete.  The ACES tracking process automatically stops if an SDX record is sent indicating the client has started receiving SSI again.

IMPORTANT:   When SSI closes, a redetermination of the client's disability status is also required, in addition to reviewing income and resource criteria.  If SSI closed because the client began receiving Title II Social Security Disability benefits, a new disability determination is not required.  However, a referral needs to be made to DDDS to determine the disability review date if the client is under the age of 65.

Disability Review date

If SSI closed for some other reason, a new referral to DDDS for a disability determination may need to be made, unless you are able to contact the local SSA field office for the disability review date, or 'diary' date which is the term used by SSA.   DDDS does not keep information about the disability review date once it sends the disability decision to the SSA field office, but SSA staff do have access to the information.   Unfortunately, the diary date information is not available through any of the department interfaces with SSA, so if you are unable to obtain the diary date, or if it is time for the client's disability status to be reviewed, a new DDDS referral for NGMA needs to be initiated.   Follow directions under the Ex-Parte review process by screening in an S02.   Then set the end date 4 months out to allow time for the disability decision to come back.  Set a barcode tickler to review the case again at that time if no disability decision was received within that time frame. 


NOTE:

When approving the S02 (or S95/S99) coverage group, remember to change the Approval Source code on the DEM2 screen from "SI" to "SA" if the client starts receiving Title II benefits.


If the client receives long-term care services under a Home and Community Waiver (HCBS) program (COPES or DDD waiver), it is important to coordinate closely with the social worker or case manager during this process to ensure medicaid coverage is not closed for these vulnerable clients.  If the client has an NSA representative, guardian or designated authorized representative, ensure copies of all letters are sent to them so they can respond on behalf of the client.  See Chapter 388-472 WAC for more information on Equal Access Services.

If the client receives services through HCS or DDD, attach a copy of the latest client CARE assessment to the NGMA referral packet (or ensure DDDS receives a copy if an electronic NGMA referral is initiated through barcode).

 

Modification Date: December 27, 2012