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EAZ
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Revised October 28, 2007 |
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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. |
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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 388-505-0110.) SSI-related persons include:
Refer to WAC 388-500-0005 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 388-448 or the Incapacity chapter in the EA-Z manual for GA-X expedited Medicaid (presumptive disability). 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 388-408-0055 and WAC 388-506-0620 for financial responsibility rules. | |||||||||||||||
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WAC 388-475-0050
Effective June 1, 2004 WAC 388-475-0050 SSI related medical -- General information. The department provides medical benefits under the 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: Age sixty five or older; Blind with: Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees; or Disabled: "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which: Can be expected to result in death; or Has lasted or can be expected to last for a continuous period of not less than twelve months; or 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. Decisions on SSI related disability are subject to the authority of: Federal statutes and regulations codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended; and Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process. 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 department unless the applicant's: Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or Medical condition has changed since the SSA denial was issued. The department considers a client 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 client is eligible for CN medical coverage under WAC 388-474-0005. Individuals referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA Z Manual sections: For all programs: WAC 388-408-0055, Medical assistance units; WAC 388-416-0015, Categorically needy and WAC 388-416-0020, Medically needy certification periods; Program specific requirements in chapter 388-475 WAC; WAC 388-490-0005, Verification; WAC 388-503-0505, General eligibility requirements for medical programs; WAC 388-505-0540, Assignment of rights and cooperation; Chapter 388-561 WAC, Trusts, annuities and life estates. (b) For LTC programs: For MN, chapter 388-519 WAC, Spenddown; For HWD, program specific requirements in chapter 388-475 WAC. Aliens who qualify for Medicaid benefits, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 388-438-0110. The department pays for a client's medical care outside of Washington according to WAC 388-501-0180. The department 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 department adopts rules that are less restrictive than those of the SSI program. Refer to WAC 388-418-0025 for effects of changes on medical assistance for re-determination of eligibility. Clarifying information CN medical is the department’s most comprehensive medical program and offers more services than MN. See Scope of Medical Services, chapter 388-529 WAC for scope of services for both CN and MN programs. Eligibility for CN medical is determined prior to eligibility for MN or other programs. 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 @ http://policy.ssa.gov/poms.nsf/lnx/0500501001. 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. 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 for SSI related CN medical assistance during the SSA determination and appeal process. The department refers people to the Division of Disability Determination Services (DDDS) for disability determinations when needing verification of blindness or disability (See Clarifying Information after WAC 388-475-0150.) For clients who need additional assistance, see Necessary Supplemental Accommodation (NSA) requirements in WAC 388-472-0010. 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. Worker Responsibility When SSA terminates a client’s SSI cash payment, but is in process of determining 1619(a) or 1619(b) eligibility for that client, change the client’s medical program from S01 (SSI recipient CN medical) to S02 (SSI related CN medical) during the SSA re-determination process. There is a value in the SDX for the final determination of 1619(a) and 1619(b) eligibility. Set an alert to check the SDX for the SSA final determination. After the SSA decision, determine eligibility for any appropriate programs based on the SSA decision. 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 388-475-0100
Effective June 1, 2004 WAC 388-475-0100 SSI related medical -- Categorically needy (CN) medical eligibility. Categorically needy (CN) coverage is available for an SSI related client who: Meets the criteria in WAC 388-475-0050, SSI related medical—General information; or Meets the criteria for the state funded general assistance expedited Medicaid disability (GA X) program by meeting the: Requirements of the cash program in WAC 388-400-0025 and WAC 388-478-0030; or SSI related disability standards but who cannot get the SSI cash grant due solely to immigration status or sponsor deeming issues. To be eligible for SSI related CN medical programs, a person must also have: Countable income and resources at or below the SSI related CN medical monthly standard (refer to WAC 388-478-0080) or be eligible for an SSI cash grant but choose not to receive it; or Countable resources at or below the SSI resource standard and income above the SSI related CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 388-475-0880; or Met requirements for long term care (LTC) CN income and resource requirements that are found in chapter 388-513 and 388-515 WAC if wanting LTC or waiver services. An ineligible spouse of an SSI recipient is not eligible for non-institutional SSI-related CN medical benefits. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for family medical programs. CLARIFYING INFORMATION 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. 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. 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 SSI-related CN medical coverage, 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. 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 MN. Clients who receive a cash general assistance (GA) grant and appear to meet SSI criteria for disability, income and resources may receive CN medical assistance under GA-X while their SSI application is pending with the Social Security Administration (SSA). Eligibility re-determinations must be completed on each person in the AU for all possible medical assistance programs before terminating medical assistance and before denying an application. 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. A resident of Washington requiring medical assistance outside the State of Washington or outside the United States is provided care according to WAC 388-501-0180. To be eligible for medical assistance, a client must cooperate with MAA’s Third Party Resources section (Refer to WACs 388-501-0200 and 388-505-0540). This refers to coordination of benefits with other insurers or individuals that may have liability for medical expenses. 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 388-475-0880. WAC 388-475-0150
Effective June 1, 2004 WAC 388-475-0150 SSI related medical -- Medically needy (MN) medical eligibility. Medically needy (MN) medical coverage is available for any of the following: A person who is SSI related and not eligible for CN medical coverage because they have countable income that is above the CN income standard (or for long term care (LTC) clients, above the special income limit (SIL)); Their countable income is at or below MN standards, leaving them with no spenddown requirement; or Their countable income is above MN standards requiring them to spenddown their excess income (see subsection (4) below). See WAC 388-475-0500 through WAC 388-475-0800 for rules on determining countable income, and WAC 388-478-0080 for program standards or chapter 388-513 WAC for institutional standards. An SSI related ineligible spouse of an SSI recipient; An adult who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 388-424-0010 for limits on eligibility for aliens; A person who meets the MN LTC services requirements of chapter 388-513 WAC and WAC 388-515-1540; A person who lives in an alternate living facility and meets the requirements of WAC 388-513-1305; or A person who meets resource requirements as described in chapter 388-475 WAC, elects and is certified for hospice services per chapter 388-551 WAC. Clients whose countable resources are above the SSI resource standards are not eligible for MN non-institutional medical benefits. See WAC 388-475-0200 through WAC 388-475-0550 to determine countable resources. Clients who qualify for services under long term care have different criteria and may spend down excess resources to become eligible for LTC institutional or waiver medical benefits. Refer to WAC 388-513-1315 and WAC 388-513-1395. A client with income over the medically needy income limit (MNIL) may become eligible for MN coverage when they have incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 388-519 WAC for spenddown information. A client may be eligible for medical coverage for up to three months immediately prior to the month of application, if the client: Met all eligibility requirements for the months being considered; and Received medical services covered by Medicaid during that time. A client eligible for MN without a spenddown is certified for up to twelve months. For an MN client with spenddown, refer to WAC 388-519-0110. For a long term care MN client, refer to WAC 388-513-1305 and WAC 388-513-1315. A client must reapply for each certification period. There is no continuous eligibility for MN. Although each additional certification period requires a new application, if the medical benefits have been closed less than thirty days, an eligibility review form may be used to reapply. CLARIFYING INFORMATION 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, Chapter 388-478 WAC. MN provides slightly less medical coverage than CN. (See Scope of Medical Services, Chapter 388-529 WAC). For MN clients with spenddown, the certification period starts either: The first of the certification period if hospital expenses meet spenddown amount; or The day spenddown is met with medical expenses if there are no hospital expenses or if the hospital expenses are less than the spenddown amount . See Certification Periods Chapter 388-416 WAC. 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 Ensure a new application is mailed to the client before the end of the base period. The three-month retroactive period of eligibility does not require a separate application. For reported changes that will alter the spenddown amount: 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. If the client has not met spenddown, recalculate the spenddown using current information and notify the client of the changes. 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. 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. 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 388-503-0505 (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: Social Security Administration (Social Security disability benefits and SSI cash grant); and DSHS SSI-related clients who: Do not receive SSI or SSA disability; Need a re-exam for continuing eligibility; Were terminated from SSI due to no longer meeting disability criteria; and Meet SSI-related income and resource standards. If a client is currently receiving SSI or SSA disability, DDDS has already determined that the person is blind or disabled. A referral is needed to get the end date of the disability determination. Set an alert for this date and get a re-determination decision from DDDS at that time. WORKER RESPONSIBILITIES FOR DISABILITY DETERMINATIONS When a blindness or disability determination is needed: Refer the case to the Social Services worker who prepares and submits material to DDDS for a disability determination. 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. Request retroactive approval if the client had a medical need in any of the three months before the month of application. 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. When DDDS returns the disability determination: 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. 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. See Fair Hearing chapter (Chapter 388-02 WAC) for fair hearing and reconsideration procedures. | |||||||||||||||
