Principles of SSI

Unit 8

Medicaid eligibility • SEC. 1634. [42 U.S.C. 1383c] (a) The Commissioner of Social Security may

enter into an agreement with any State which wishes to do so under which the Commissioner will determine eligibility for medical assistance in the case of aged, blind, or disabled individuals under such State's plan approved under title XIX. Any such agreement shall provide for payments by the State, for use by the Commissioner of Social Security in carrying out the agreement, of an amount equal to one-half of the cost of carrying out the agreement, but in computing such cost with respect to individuals eligible for benefits under this title, the Commissioner of Social Security shall include only those costs which are additional to the costs incurred in carrying out this title.

• (b)(1) An eligible disabled widow or widower (described in paragraph (2)) who is entitled to a widow's or widower's insurance benefit based on a disability for any month under section 202(e) or (f) but is not eligible for benefits under this title in that month, and who applies for the protection of this subsection under paragraph (3), shall be deemed for purposes of title XIX to be an individual with respect to whom benefits under this title are paid in that month if he or she—

What is Medicaid?

• Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.

• Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services.

Medicaid is a state adminis

Requirements

• age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant.

• There are special rules for those who live in nursing homes and for disabled children living at home.

Children

• Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents)

• Eligibility for children is based on the child's status, not the parent's

• if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child

When Eligibility Starts

• Coverage may start retroactive to any or all of the 3 months prior to application, if the individual would have been eligible during the retroactive period

• Coverage generally stops at the end of the month in which a person's circumstances change

What is Not Covered

• Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups

• Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds

What is Medicare?

• Medicare is a health insurance program for people 65 years of age and older, some disabled people under 65 years of age, and people with end-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant)

• Medicare has two parts. Part A is hospital insurance. Most people do not have to pay for Part A. Part B is medical insurance. Most people pay monthly for Part B

Will a beneficiary get Medicare coverage?

• Everyone eligible for Social Security Disability Insurance (SSDI) benefits is also eligible for Medicare after a 24-month qualifying period. The first 24 months of disability benefit entitlement is the waiting period for Medicare coverage

• During this qualifying period for Medicare, the beneficiary may be eligible for health insurance through a former employer. The employer should be contacted for information about health insurance coverage

How are months counted?

• SSA counts one month for each month of disability benefit entitlement

What happens to Medicare coverage if a beneficiary works?

• A beneficiary may receive at least 93 months of hospital and medical insurance after the trial work period as long as he or she still has a disabling impairment

• This provision allows health insurance to continue when a beneficiary goes to work and engages in substantial gainful activity. The beneficiary does not pay a premium for hospital insurance

SSI Applicants and Medicaid Benefits

• In most states, if you are an SSI beneficiary, you may be automatically eligible for Medicaid; an SSI application is also an application for Medicaid

• In other states, you must apply for and establish your eligibility for Medicaid with another agency. In these states, we will direct you to the office where you can file for Medicaid

Cont’d

• States pay the Medicare premiums for people who receive SSI benefits if they are also eligible for Medicaid

• If you get SSI and have Medicare, you will also be eligible for extra help without filing a separate application

How to qualify

• Medicaid is a jointly funded, Federal-State health insurance program for low-income and needy people

• It covers children, the aged, blind, and/or disabled and other people who are eligible to receive federally assisted income maintenance payments

Cont’d

• Thirty-two states and the District of Columbia provide Medicaid eligibility to people eligible for Supplemental Security Income (SSI ) benefits. In these States, the SSI application is also the Medicaid application. Medicaid eligibility starts the same months as SSI eligibility

Cont’d

• The following jurisdictions use the same rules to decide eligibility for Medicaid as SSA uses for SSI, but require the filing of a separate application: Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah, Northern Mariana Islands

Cont’d

• The following States use their own eligibility rules for Medicaid, which are different from SSA`s SSI rules. In these States a separate application for Medicaid must be filed: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, Virginia

What happens to Medicaid coverage if a SSI recipient works?

• If a recipient’s State provides Medicaid to people on SSI, the recipient will continue to be eligible for Medicaid

• Medicaid coverage can continue even it a recipient’s earnings along with other income become too high for a SSI cash payment

How does a recipient qualify?

• To qualify, a recipient must: • Have been eligible for an SSI cash payment for

at least one month; • Still be disabled; • Still meet all other eligibility rules, including the

resources test; • Need Medicaid in order to work; and • Have gross earned income that is insufficient to

replace SSI, Medicaid, and any publicly funded attendant care

How Does Employment Affect SSI Medicaid Eligibility?

• To qualify for continuing Medicaid coverage, a person must:

• Have been eligible for an SSI cash payment for at least 1 month;

• Still meet the disability requirement; and • Still meet all other non-disability SSI

requirements; and • Need Medicaid benefits to continue to work; and • Have gross earnings that are insufficient to

replace SSI, Medicaid and publicly funded attendant care services

SSA uses a threshold amount to measure whether a person’s earnings are high enough to replace his/her SSI

and Medicaid benefits. This threshold is based on the:

• amount of earnings which would cause SSI cash payments to stop in the person’s State; and

• average Medicaid expenses in that State.

If a SSI beneficiary has gross earnings higher than the threshold amount for his/her State, SSA can figure an

individual threshold amount if that person has: • Impairment-related work expenses; or

• Blind work expenses: or

• A plan to achieve self-support; or

• Personal attendant whose fees are publicly funded; or

• Medical expenses above the average State amount.