MEDICAL RE-DETERMINATION
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MEDICAL RE-DETERMINATION


Revised April 19, 2012


SSI-RELATED SPECIAL INCOME DISREGARDS


See WAC 182-512-0880 for more information relating to the policy for the SSI-related special income disregards.

When SSI cash assistance closes due to the receipt of Title II Social Security Income, ACES does several automated checks to determine if the client would continue to qualify for CN medical assistance due to application of one or more of the special income disregards:

  • The "Application/Benefit" field on the bottom of the UNER screen is used to identify the reason and date a client was terminated from SSI. 
  • ACES automatically populates the 'Ever Received SSI?" field with a 'Y'(Yes) and adds the SSI closure date when an SDX record is received showing the client is no longer in pay status for SSI.
  • ACES changes the SSI payment amount to $0.00.
  • When ACES is able to identify that the reason for the SSI closure was due to a cost of living increase (COLA), receipt of Disabled Adult Child (DAC) benefits or receipt of widow(er) income, it adds the correct closure reason code to the bottom of the UNER screen.
  • If ACES is unable to determine the reason for the the SSI closure, you need to manually update the closure codes with the correct information while completing the eligibility review required for the redetermination process.

 


NOTE:

Review the SDX or SOLQ for prior SSI information if the bottom of the UNER screen does not show any SSI closure information.  SDX records do not display if a client received SSI in another State and it terminated prior to the client moving to Washington.  If the SSI information is not readily available, check with the client, if possible, or ask for additional verification if the information is questionable.

 


SSI closure codes are available to help identify clients who are eligible for an SSI-related special income disregard.  These codes are:

H - Receipt of DAC Benefits, or a COLA to DAC benefits

I - Receipt of Widows Benefits (Group 1)

J - Receipt of or COLA to Widow/Widowers/Surviving Spouse Benefits (Group 2)

K - SSI terminated for any other reason and the client received Title II benefits at the time of termination or by the time ACES re-checks for Title II benefits 60 days after termination. (Pickle disregard)

T - SSI terminated for any other reason and client did NOT receive Title II benefits at the time of termination or within 60 days of the termination.

U - Unable to determine the reason for the SSI termination.  This is a system generated code and must be updated to the correct value at the next review or application.

C - Old code prior to October 2009. 


Disabled Adult Child (DAC) disregard

The DAC disregard applies to clients who lose eligibility for SSI due to the receipt of DAC benefits or a cost of living increase (COLA) to DAC benefits.  To receive DAC income, a client must have been found disabled prior to their twenty-second birthday.  A client who receives DAC income but who has never been eligible for SSI is NOT eligible for the DAC disregard.

For ACES to apply the DAC disregard, the following criteria must be met:

  • Client has unearned income type 'SC' in an amount greater than zero.
  • Client is 18 years of age or older.
  • Client meets the aged, blind or disabled criteria.
  • Client has an SSI closure date that is equal to or later than 7/1/88.
  • The Application/Benefit status field on the UNER screen is coded with an 'H'.
  • Net countable income after applying the disregard is below the SSI categorically needy income level.
  • The client meets all other SSI-related CN medical requirements.

When ACES receives an SDX record where the Medical Eligibility code is 'D' and there is Title II income type 'SC', ACES automatically updates the SSI closure information on the UNER screen and enters the 'H' code.  If the client returns the eligibility review sent at the time of the SSI closure, screen in an S02 medical AU and process, allowing the S01 AU to close.

If the client is eligible for the disregard, the entire amount of the DAC income is excluded in the CN income calculation.  You will be able to determine if the disregard was applied by reviewing the MAFI screen.  If DAC income was disregarded, ACES will indicate this by displaying a 'D ' in the Disregard Applied field.  If both DAC and the Pickle disregard are applied, ACES displays an 'E' on the MAFI screen.


Widow(er) Group 1 Disregard (Additional Reduction Factor (ARF) Widows)

The widow(er) Group 1 disregard applies only to a small group of clients who meet specific age criteria.  When Social Security amended how it calculated Title II benefits for widow(er)s in 1983, the change resulted in an increase in Title II income and the loss of SSI benefits for a number of clients.  These clients were grandfathered into continued CN medicaid eligibility.

For ACES to apply the Widow(er) Group 1 disregard, the following criteria must be met:

  • Client has unearned income type 'SW' in an amount greater than zero.
  • Client's date of birth is greater than 12/31/1923 and less than 01/01/1934.
  • Client meets the aged, blind or disabled criteria.
  • Client has an SSI closure date on the UNER screen that is after 12/31/1983 and before 02/01/1984.
  • The Application/Benefit status field on the UNER screen is coded with an 'I'.
  • Net countable income after applying the disregard is below the categorically needy income level.
  • The client meets all other SSI-related CN medical requirements.

SSA no longer sends information about these clients on the SDX records so automatic updates do not happen for this group. 

If the client is eligible for the disregard, the entire amount of the widow(er) income is excluded in the CN income calculation.  You will be able to determine if the disregard was applied by reviewing the MAFI screen.  If widow(er)s income was disregarded, ACES will indicate this by displaying a 'W' in the Disregard Applied field.  If both widow(er) Group 1 and the Pickle disregard are applied, ACES displays an 'X' on the MAFI screen.


Widow(er) Group 2 Disregard (Early Widows)

The widow(er) Group 2 disregard applies to clients who lose SSI eligibility due to a mandatory application for Title II widow(er) benefits or due to a COLA to those benefits.  The disregard protects CN eligibility for these clients until they are entitled to receive Medicare.  Clients who meet these criteria also automatically meet the criteria for the Pickle disregard if they have income from another Title II source. 

For ACES to apply the Widow(er) Group 2 disregard, the following criteria must be met:

  • Client has unearned income type 'SW' or 'SB' in an amount greater than zero.
  • Client is currently age 50 and not yet age 65.
  • Client meets the blind or disabled criteria.
  • Client has an SSI closure date on the UNER screen that is equal to or after 01/01/1991. 
  • Client is not eligible for Medicare Part A.
  • The Application/Benefit status field on the UNER screen is coded with a 'J'
  • Net countable income after applying the disregard is below the categorically needy income level.
  • The client meets all other SSI-related CN medical requirements.

When ACES receives an SDX record where the medical eligibility code is 'W' and there is Title II income type 'SW' or 'SB', ACES automatically updates the SSI closure information on the UNER screen and enters the 'J' code.  If the client returns the eligibility review sent at the time of the SSI closure, screen in an S02 and process and allow the S01 AU to close. 

If the client is eligible for the disregard, the entire amount of the widow(er) income is excluded in the CN income calculation.  You will be able to determine if the disregard was applied by reviewing the MAFI screen.  If widow(er) income was disregarded, ACES will indicate this by displaying an 'S' in the Disregard Applied field.  If both widow(er) and the Pickle disregard are applied, ACES displays an 'R' on the MAFI screen.


Pickle

The Pickle disregard applies to individuals who lose SSI eligibility due to the receipt of Title II benefits or a COLA to the Title II benefits.  A client must have been entitled to both SSI and the Title II benefits within the same month for the Pickle disregard to apply, however this does not mean that the client must have received an SSI check and a Title II check in the same month.  Since Title II benefits pay in arrears and are actually for the month preceding the month in which the payment is issued, an individual who loses SSI in one month and receives Title II income the month following is considered to have met the criteria to be considered for the Pickle disregard.   


EXAMPLE

Daphne receives her last SSI check in June 2012 and starts receiving Social Security disability income of $730 per month on July 1st, 2012.  Since the July 1 SSDI check is for the month of June and she received SSI in June, she meets the criteria for the Pickle disregard. 

In this example, even though she meets the criteria for Pickle and should be coded as a Pickle eligible client in ACES, the Pickle disregard does not make her CN eligible.  After allowing the $20 SSI-related income exclusion, her net countable income is over the CNIL standard of $698 (effective 01/2012). 

However, in subsequent years, her 'frozen' Title II benefit of $730 may fall below the future CNIL standard depending on the increases in the Federal Benefit Rate.  If this happens, she will be eligible for the Pickle disregard at that time.


For ACES to apply the Pickle disregard, the following criteria must be met:

  • The client must receive Title II income either in the same month as they received SSI or in the month immediately after they stopped receiving SSI.  In ACES, this means there must be unearned income type SD, SS, SC, SW or SB in an amount greater than zero.
  • The SSI closure date is after 04/30/1977.
  • Client meets the aged, blind or disabled criteria.
  • The Application/Benefit status field on the UNER is coded with an 'H', 'I', 'J', or 'K'.
  • Net countable income after applying the disregard is below the SSI Categorically Needy Income Level.
  • The client meets all other SSI-related CN medical requirements.

When ACES receives an SDX record showing SSI income has terminated, there may or may not already be Title II income in the record.  The BENDEX interface, which updates the Title II Social Security income, may be received after the original SDX record.

  • If there is Title II income type 'SD' or 'SS' already coded in ACES, then ACES automatically updates the SSI closure information in the Application/Benefit field on the UNER screen and enters the 'K' Pickle indicator code.
  • If there is no Title II income in the record, ACES updates the status code to a 'U' Unknown and wait for the BENDEX record to come in.  ACES will check the record again in 60 days to see if Title II income was added to the case record. 
  • At the time of the 60 day check, if no Title II income was added, or if the existing income has been removed, ACES automatically changes the Application/Benefit Status field to a 'T' Terminated and applies no disregards.
  • If another source of Title II income is added to the case prior to the 60 day check, then ACES changes the 'U' or 'K' code to 'H' if the income type that was added is 'SC' or to a 'J' if the income type that was added is 'SW' or 'SB'.

When the client provides the eligibility review sent at the time of SSI closure, screen in an S02 medical AU and process, allowing the S01 AU to close.  Review the coding on the bottom of the UNER screen to determine if the correct disregards are being applied. 

If the client is eligible only for the Pickle disregard, then just the cost of living increases received since SSI was terminated will be excluded in the CN income calculation.  You can determine if the disregard was applied by reviewing the MAFI screen.  If the Pickle disregard is allowed, ACES indicates this by displaying a 'P' in the Disregard Applied field.


NOTE:

Clients may not be CN eligible under Pickle criteria at the time of the SSI closure but may become eligible for the disregard in subsequent years depending on income.  Always review MN spenddown cases for the correct coding before establishing a spenddown liability. 

 


EXAMPLE

Jody lost SSI in May 2003 due to the receipt of $513 in SS disability income.  In addition Jody received a small pension benefit of $104.  She met the criteria for the Pickle disregard, however her gross income of $617 minus the $20 income exclusion (net income, $597) was over the 2003 SSI payment standard of $552.  

It is now 2009.  Each year, since 2003, Jody's SSDI income has increased due to cost of living increases but her pension benefit remained the same amount.  Now her SSDI income is $625.  However, since she meets the Pickle criteria, her countable SSDI amount is the 'frozen' amount of $513 she was paid in 2003.  Now, when you compare the 2003 net income amount of $597 to the current 2009 federal benefit rate of $674, her income is below the standard and she is CN eligible. 

You need to screen in an S02 and close out the MN spenddown for this client so that her correct Medicaid eligibility can be established.  

Modification Date: April 19, 2012