SSI-Related Medical - General
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SSI-Related Medical - General


Revised May 2, 2014



Purpose: This chapter describes the eligibility requirements for the Categorically Needy (CN) and Medically Needy (MN) medical programs for SSI-related persons. SSI-related persons are those who meet the requirements of aged, blind or disabled, as defined by the federal SSI program rules, but cannot get or choose not to receive SSI cash benefits. (See PROGRAM SUMMARY and SSI chapters of the EA-Z manual.) For rules concerning clients who need additional help or Necessary Supplemental Accommodation (NSA) see chapter 388-472 WAC.

WAC 182-512-0050SSI related medical -- General information
WAC 182-512-0100SSI related medical -- Categorically needy (CN) medical eligibility.
WAC 182-512-0150SSI-related medical -- Medically needy (MN) medical eligibility

WAC 182-512-0050

WAC 182-512-0050

Effective October 1, 2013

WAC 182-512-0050 SSI related medical -- General information



(1) The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) categorically needy (CN) and medically needy (MN) SSI-related programs for SSI-related people, meaning those who meet at least one of the federal SSI program criteria as being:

(a) Age sixty-five or older;

(b) Blind with:

(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.

(c) Disabled:

(i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:

(A) Can be expected to result in death; or

(B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

(C) In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.

(ii) Decisions on SSI-related disability are subject to the authority of:

(A) Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and

(B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.

(2) A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the agency unless the applicant's:

(a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or

(b) Medical condition has changed since the SSA denial was issued.

(3) The agency considers a person who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a person is eligible for WAH CN health care coverage under WAC 182-510-0001.

(4) Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:

(a) For all programs:

(i) WAC 182-506-0015, Medical assistance units;

(ii) WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;

(iii) Program specific requirements in chapter 182-512 WAC;

(iv) WAC 182-503-0050, Verification;

(v) WAC 182-503-0505, General eligibility requirements for medical programs;

(vi) WAC 182-503-0540, Assignment of rights and cooperation;

(vii) Chapter 182-516 WAC, Trusts, annuities and life estates.

(b) For LTC programs:

(i) Chapter 182-513 WAC, Long-term care services;

(ii) Chapter 182-515 WAC, Waiver services.

(c) For WAH MN, chapter 182-519 WAC, Spenddown;

(d) For WAH HWD, program specific requirements in chapter 182-511 WAC.

(5) Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.

(6) The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.

(7) The agency follows income and resource methodologies of the supplemental security income (SSI) program defined in federal law when determining eligibility for SSI-related medical or medicare cost savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.

(8) Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

This chapter includes sections on the following eligibility criteria:

CN and MN medical programs provide medical benefits for people who are blind, disabled, or who are age 65 or older. CN and MN include some special income disregards (See WAC 182-508-0001 and WAC 182-512-0880.) SSI-related persons include:

  • Adults with no children, or adults who are not covered under family medical programs, including Long-term Care clients;
  • Working age adults (18-64) with disabilities who are working and have income or resources that exceed other SSI-related program requirements; See Clarifying Information that follows WAC 182-511-1100 in the Healthcare for Workers with Disabilities (HWD) section for more information and rules that apply to all clients with gross monthly earnings at or above substantial gainful activity (SGA). For the SGA amount, see SSA "Substantial Gainful Activity - Amounts for 2013."  
  • The SGA test described in  WAC 182-512-0050 below applies to all SSI-related programs (other than non-grant medical assistance (NGMA), including HWD, and Medicaid coverage provided under sections 1619(a) and (b) of the Social Security Act), unless the client continues to receive a Title 2 cash benefit, e.g. SSDI or DAC;   
  • Children who are blind or disabled and who are not receiving SSI (See WAC 182-505-0210); and
  • Certain qualified aliens who are non-citizens but otherwise meet the criteria for SSI-related medical (See WAC 182-508-0001).

Refer to WAC 182-500-0005 for definitions of terms used in this chapter.

Refer to WAC 388-519-0100 for persons eligible for MN medical.

Refer to Chapter 388-474 WAC for SSI recipients.

Refer to WAC 388-449-0001 for Aged, Blind, Disabled cash assistance.

Refer to chapters 388-513 and 388-515 WAC for Long Term Care (institutional and waiver services), or chapter 388-551 WAC for hospice services.

Refer to WAC 182-506-0010 and WAC 182-512-0900 through WAC 182-512-0960 for financial responsibility rules.


NOTE: Individuals receiving Title 2 cash benefits may test their ability to work for a number of months without losing their cash benefit under the SSA Trial Work Period (TWP).  After the TWP is completed, earnings at the SGA level result in the loss of Title 2 cash after a three-month "cessation and grace" period.  For more information about the TWP, see SSA work incentives.

Clarifying information

  1. CN medical is the department’s most comprehensive medical program and offers more services than MN. See Scope of Care for scope of services for both CN and MN programs. Eligibility for CN medical is determined prior to eligibility for MN or other programs.

  2. The department uses the Federal SSI cash assistance rules when determining eligibility for SSI-related medical with a few exceptions that provide less restrictive rules, which are covered in this chapter. Refer to SSA Program Operating Manual Systems (POMS) for more comprehensive definitions of blind and disabled @ SI 00501.001 Eligibility Under the Supplemental Security Income Provisions.

  3. A client who receives cash assistance from SSI, SSA disability, or who is age 65 or older has met the requirements to be SSI-related and no further categorical determination is necessary. See NOTES below.

  4. An SSI client who begins working and is terminated from SSI cash benefits by the Social Security Administration, but who is being determined for eligibility under the Social Security Act Title 1619(a) or 1619(b), remains eligible as an SSI recipient under the S01 CN medical coverage group during the SSA determination and appeal process.

  5. The department refers people to the Division of Disability Determination Services (DDDS) for disability determinations when needing verification of blindness or disability (See "Worker Responsibilities" after WAC 182-512-0150).

  6. For clients who need additional assistance, see Necessary Supplemental Accommodation (NSA) requirements in WAC 388-472-0010.

  7. A client found ineligible for a specific medical program is continued on medical assistance while a re-determination is completed to see if he/she is eligible for any other medical programs.


NOTE: An eligible client may choose to enroll in Healthcare for Workers with Disabilities (HWD) with gross monthly earnings above or below the substantial gainful activity (SGA) level.  If a client is working at SGA and never received a federal cash benefit based on disability, or no longer receives it because of earnings, then HWD is the only Medicaid option for coverage, unless Medicaid protections under Section 1619 of the Social Security Act apply.

NOTE: An impairment-related work expense (IRWE) approved by SSA or the financial worker may be used to reduce gross earnings that are compared to SGA. For information about IRWEs, see WAC 182-512-0840 and SSA Red Book - Employment Supports.

NOTE: Determinations made by SSA to establish IRWEs or a subsidy and special conditions exist in their "eWork" and Disability Control File (DCF) databases; such information is not provided in a Benefits Planning Query (BPQY) and is not available in any other SSA database. If current documentation is not available, SSA staff can help determine whether an individual with higher earnings is working at SGA.

Worker Responsibility

  1. When SSA terminates a client’s SSI cash payment, but is in process of determining 1619(a) or 1619(b) eligibility for that client, continue the client on S01 medical until you receive additional information on the SDX referring the client back to the State for a medicaid determination (R on the medical eligibility field on SDX1).  While the client is in 1619(b) status, SSA sends notification to the State on the SDX interface using the 'C' code in the medical eligibility field on the SDX1.  After the SSA sends the final decision on the SDX record, determine eligibility for any appropriate programs based on the SSA decision.

  2. When SSA terminates the client’s SSI cash eligibility for reasons other than disability ending or improvement, a new referral to DDDS is needed to get the disability end date – the date a new disability determination will be needed. Set an alert at least 90 days prior to the disability end date to begin the process of getting the new disability determination from DDDS.


WAC 182-512-0100

WAC 182-512-0100

Effective October 1, 2013

WAC 182-512-0100 SSI related medical -- Categorically needy (CN) medical eligibility.



(1) Washington apple health (WAH) categorically needy (CN) coverage is available for an SSI-related person who meets the criteria in WAC 182-512-0050, SSI-related medical—General information.

(2) To be eligible for SSI-related WAH CN medical programs, a person must also have:

(a) Countable income and resources at or below the SSI-related WAH CN medical monthly standard (refer to WAC 182-512-0010) or be eligible for an SSI cash grant but choose not to receive it; or

(b) Countable resources at or below the SSI resource standard and income above the SSI-related WAH CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 182-512-0880; or

(c) Met requirements for long-term care (LTC) WAH CN income and resource requirements that are found in chapters 182-513 and 182-515 WAC if wanting LTC or waiver services.

(3) An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related WAH CN health care coverage. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for family medical programs.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. A client who is eligible for an SSI cash grant and chooses not to accept it is still eligible for CN medical as an SSI-related client.

  2. A client receiving other types of disability benefits, such as VA, L&I, RRB, etc., is not automatically considered SSI-related. The client must meet the aged, blind or disabled criteria of the federal SSI or SSA program, as determined by DDDS.

  3. A working client who meets the special requirements for SSI status, under the 1619 (a) and/or (b) provisions of the Social Security Act, is considered an SSI recipient eligible for CN medical under the S01 coverage group, but may not receive a cash grant. An SDX code will identify the 1619 client as an SSI recipient with a Medical Eligibility Code of C.

  4. The ineligible spouse of an SSI recipient, who does not receive SSI in his or her own right but is included in the spouse’s benefits, is not considered an SSI recipient for purposes of SSI-related medical. The spouse must apply for medical and have SSI-related eligibility determined separately. An SSI-ineligible spouse can not receive non-institutional CN medical, but may qualify for medically needy (MN) coverage.

  5. Clients who receive a cash grant under the Aged, Blind, Disabled cash program and meet SSI criteria for disability, income and resources may receive CN medical assistance while their SSI application is pending with the Social Security Administration (SSA).

  6. Eligibility re-determinations must be completed on each person in the AU for all possible medical assistance programs before terminating CN medical assistance and before denying an application.

  7. The eligibility processes for adults who meet the long-term care requirements are found in the LONG-TERM CARE chapter of the EA-Z Manual, or Chapters 388-513 or 388-515 WAC.

  8. A resident of Washington requiring medical assistance outside the State of Washington or outside the United States is provided care according to WAC 182-501-0180.

  9. To be eligible for medical assistance, a client must cooperate with the Health Care Authority's (HCA) Third Party Resources section (Refer to WACs 182-501-0200 and 182-503-0540). This refers to coordination of benefits with other insurers or individuals that may have liability for medical expenses.

  10. Detailed information about SSI-related Special Income Disregards (e.g., the COLA disregard, Disabled Widow/Widowers Income Disregard, DAC Income Disregard, and SSP Income Disregard) is contained in the Income Disregards Section of this chapter in WAC 182-512-0880.


WAC 182-512-0150

WAC 182-512-0150

Effective October 1, 2013

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility



(1) Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:

(a) A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):

(i) The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or

(ii) The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.

(b) An SSI-related ineligible spouse of an SSI recipient;

(c) A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;

(d) A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;

(e) A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1305; or

(f) A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.

(2) A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.

(3) A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.

(4) A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.

(5) A person may be eligible for health care coverage for up to three months immediately prior to the month of application, if the person has:

(a) Met all eligibility requirements for the months being considered; and

(b) Received medical services covered by medicaid during that time.

(6) A person who is eligible for WAH MN without a spenddown is certified for up to twelve months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1305 and 182-513-1315.

(7) A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. The Medically Needy (MN) program provides a federal and state-funded Medicaid benefit for certain persons with income above Categorically Needy (CN) standards. Those amounts are defined in Standards.  SSI related CN standards are described in WAC 182-512-0010.   MN standards  are described in WAC 182-519-0050.  MN provides slightly less medical coverage than CN. See Scope of Care.

  2. For MN clients with spenddown, the certification period starts either:

    • The first of the certification period if the client meets the spenddown with only Medicare cost sharing expenses, private insurance cost-sharing expenses, prior unpaid bills, or expenses of the type that are not covered under DSHS medical programs (or any combination of these); or

    • The day spenddown is met if the expenses are hospital expenses, medical expenses of the type that are potentially payable by DSHS medical programs or prescription expenses (non Medicare Part D expenses).

    • See Certification Periods Chapter 182-504 WAC.

  3. There is no automatic re-determination process for MN at the end of a certification period. A client must apply for each certification period. See Chapter 388-472 WAC for rules concerning clients who need additional help, or Necessary Supplemental Accommodation (NSA).


WORKER RESPONSIBILITIES

  1. Ensure a new application is mailed to the client before the end of the base period.

  2. The three-month retroactive period of eligibility does not require a separate application.

  3. For reported changes that will alter the spenddown amount:

    1. If the client has met spenddown, no change can be made for previous months. Recalculate spenddown for the remaining base period using the new information. If the change increases the spenddown, changes are effective the month after the month of change, following the rules of advance and adequate notice. If the change makes the client eligible for CN, make those changes for the appropriate months. Be sure to send an award letter explaining the changes.

    2. If the client has not met spenddown, recalculate the spenddown using current information and notify the client of the changes.  See Change of Circumstances section of the Spenddown chapter of the manual.

  4. Allow a client 30 days after the base period has expired to send in bills to meet spenddown. It may take this long for the client to gather medical bills. If the client requests more time to send bills in, allow it. If a fair hearing is filed, allow the client to continue submitting bills incurred during the established base period until the fair hearing is resolved. Provide any necessary additional assistance if the client is determined to be NSA.

  5. Determine eligibility for all other medical assistance programs for which any persons in the AU may be eligible before terminating medical assistance and before denying an application.

  6. An SSI-related client residing in a public institution is not eligible for Medicaid under either CN or MN. See Program Summary  in the EA-Z Manual and WAC 182-503-0505 (5) General Eligibility.


REFERRAL PROCESS TO DIVISION OF DISABILITY DETERMINATION SERVICES (DDDS):

In Washington State, DDDS makes the blindness and disability determinations for clients of both:

  1. Social Security Administration (Social Security disability benefits and SSI cash grant); and

  2. DSHS SSI-related clients who:

    1. Do not receive SSI or SSA disability;

    2. Need a re-exam for continuing eligibility;

    3. Were terminated from SSI due to no longer meeting disability criteria;

    4. Meet SSI-related income and resource standards; or

    5. Have gross monthly earnings at or above the current substantial gainful activity (SGA) level. (See SSA "Substantial Gainful Activity - Amounts for 2013.") For more information about SGA, see the SSA Red Book.

  3. If a client is currently receiving SSI or SSA disability, DDDS has already determined that the person is blind or disabled.


WORKER RESPONSIBILITIES FOR DISABILITY DETERMINATIONS

  1. When a blindness or disability determination is needed:

    1. For the client with gross monthly earnings at or above SGA, or resources that exceed the SSI standard, the Specialized Medical Team (SMT) facilitates the referral to DDDS for a NGMA determination of disability for HWD Medicaid Only. When routing HWD applications or case records to SMT, send them via DMS under @HWD CSO 157. HWD voice message line is (206) 272-2169 or 1 (800) 871-9275. 

    2. For all other clients, who may or may not be working, and if so - have gross monthly earnings below SGA - follow local procedures for completing the NGMA process at the local office.

    3. Advise the social services worker if there already is a pending application for SS disability or SSI benefits. The social worker can track the pending application with DDDS.

    4. Request retroactive approval if the client had a medical need in any of the three months before the month of application.

    5. Pend the application. Take no action until a decision is received from DDDS. This may take more than 60 days. Document the reason for delays beyond 60 days from the date of application in ACES.

  2. When DDDS returns the disability determination:

    1. If the client meets the disability criteria, open medical care in the appropriate category, based on income and resources. Be sure to include the end date as well as the determination date on the DEM2 ACES screen, and send a request for a re-determination to the Social Worker at least 90 days prior to the review end date. If the re-exam has been waived by DDDS, no end date is required.

    2. If the client does not meet the disability criteria, consider the client for all other medical programs or allow the client to provide new medical information to be forwarded to DDDS for reconsideration.

  3. See Fair Hearing chapter (Chapter 388-02 WAC or Chapter 288-526 WAC) for fair hearing and reconsideration procedures.


NOTE:

A client with gross monthly earnings below SGA who applies for non-institutional Medicaid, and for whom disability status for NGMA is established by DDDS, must be considered for S02 eligibility. Such cases remain at the local CSO.

Modification Date: May 2, 2014