1. Understanding Special Medicaid

2. Learning Objectives
Upon completion of this training, participants will be able to:
Identify and describe the 3 categories of Special Medicaid benefits;
Describe the eligibility requirements for each of the 3 Special Medicaid groups;
Describe how paid employment affects eligibility for Special Medicaid; and
Describe the CWIC’s role in providing work incentives counseling about Special Medicaid. 2

3. Some Medicaid Basics
Whatever the program, people receive Medicaid coverage because they meet two criteria:
They belong to a specific covered group; and
They meet the income and resource tests necessary for members of that group to receive benefits. 3

4. Special Medicaid Groups
Former SSI recipients who lose eligibility for SSI cash benefits …
for any reason, but who would have been eligible for SSI if the SSDI cost of living adjustment (COLAs) at the point of or after SSI termination were excluded as income (Pickle);
because of entitlement to or an increase in Childhood Disability Benefits (CDB); or
because of entitlement to Disabled Widow(er)s Benefits (DWB) with some limitations. 4

5. Special Medicaid Exclusions
When determining Medicaid eligibility for these special former SSI recipients, State Medicaid Agencies must exclude that portion of the individual’s applicable Title II disability benefit that caused ineligibility for SSI. That may be the entire payment, increases in the payment, or (in the case of Pickle), COLAs 5

6. How the Exclusions Work
If, by excluding the appropriate portion of the Title II benefit, the individual would otherwise be eligible for SSI cash payments or 1619(b), the person is deemed eligible for Medicaid.
These individuals are “deemed” SSI recipients for Medicaid purposes, though they are NOT entitled to SSI cash benefits or SSI related Medicaid and are not listed on Social Security’s SSI rolls. 6

7. Clarification of Terms
The terms “SSI program” and “SSI benefits” mean the individual may either be receiving cash benefits under Title XVI (SSI) or be a 1619(b) participant who is receiving Medicaid benefits, but not SSI cash payments.
Individuals in either of these categories are considered to be receiving SSI benefits and are eligible to participate in the special Medicaid groups. 7

8. Who Makes Eligibility Determinations
State Medicaid Agencies or their designees determine eligibility for Special Medicaid protections for former SSI recipients.
Social Security does NOT decide who is eligible, but may provide information about why SSI was lost and amount of Title II payment that caused loss. This information is shared thru the SDX rolls. 8

9. The Pickle Amendment
Allows individuals who receive SSDI and lose SSI entitlement for any reason to continue Medicaid if:
The individual continues to meet Social Security’s disability standard; and
countable unearned income is below applicable SSI rate when COLAs are excluded; and
All other SSI requirements are met (resource test, earnings below 1619(b) threshold at the point the person loses SSI, etc.). 9

10. Eligibility for Pickle
Is receiving SSDI benefits;
Lost SSI, but would still be eligible for those benefits if the total amount of the Title II COLAs received since losing SSI benefits while also entitled to Title II benefits was deducted from income. Cost-of-living increases include the increases by the individual, spouse or financially responsible family member; and
Was eligible for and receiving SSI concurrently with SSDI for at least one month after April 1, 1977. 10

11. Misconceptions about “Concurrently”
The individual simply needs to be “entitled” to both SSDI and SSI for the same month.
There is a one-month lag in SSDI payments, which are not disbursed until the month after entitlement. SSI payments are paid in the month of entitlement.
Even though the person never actually received simultaneous payments from both programs in a single month, he/she would meet the first Pickle requirement. 11

12. Misconceptions about “Causality”
There is a common belief that the annual Title II program COLA must have been the cause of the loss of SSI or 1619(b) in order to qualify for Pickle provisions. This is not the case and hasn’t been since a series of court decisions were made in the early 1980s.
The pivotal issue for Pickle eligibility is whether the person would otherwise be eligible for SSI or 1619(b) if the SSDI COLAs were deducted. 12

13. Felipe Example
Felipe was receiving SSDI in the amount of $737 with $4 of SSI in He was not working and had no other form of income.
Felipe’s 2015 COLA raised his SSDI benefit to $743. Since this amount was over the 2015 FBR +$20 ($721 + $20 = $741) in 2015, Felipe was no longer eligible for SSI.
What would happen to Felipe’s Medicaid in this situation? 13

14. How the Pickle Amendment Helps Felipe
In Felipe’s situation, the Medicaid agency must exclude the increase between $737 and $743 ($6) that caused Casey to lose eligibility for SSI and SSI related Medicaid.
In effect, Felipe’s SSDI benefit is “frozen” at $737 for the purposes of Special Medicaid eligibility.
Since Felipe has no other income and resources meet the SSI limits, he is eligible for continued Medicaid under the Pickle Amendment. 14

15. Watch for Pickle
There are many current SSDI beneficiaries who lost SSI years ago who are potentially eligible for Medicaid under the Pickle provisions.
Eligibility for Pickle Medicaid can be established at ANY time – there is no “statute of limitations” or sunset date.
Always ask SSDI beneficiaries about former SSI eligibility and check for Pickle Medicaid eligibility.
See attached Pickle Screening Tool. 15

16. Childhood Disability Benefits
Section 1634 of the Social Security Act requires States to consider title II Childhood Disability Beneficiaries (CDBs) who lose SSI eligibility as if they were still SSI recipients for Medicaid purposes, as long as they would have remained otherwise eligible for SSI benefits but for their entitlement to (or increase in) CDB benefits. 16

17. Sofie Example
Sofie was receiving CDB payments based on her father’s work record. While her father was alive, Sophie received $500 of CDB and $253 in SSI each month.
Sofie’s father died recently, however, and her CDB benefit was increased to the survivor’s benefit level of $760. This caused her to be ineligible for SSI.
Will Sophie keep her Medicaid? 17

18. More about Sofie
The State Medicaid Agency must exclude the $260 difference between what Sofie was receiving before her father’s death, and what she currently receives.
In effect, Sofie’s CDB is “frozen” at $500 for the purposes of Medicaid eligibility.
If Sofie has no other income and has resources under the SSI limit, she would probably be eligible for Special Medicaid. If she has other income, she may or may not be eligible for Medicaid, depending on the type and amount of the income. 18

19. Lauren Example
Lauren is 20 and receives $733 in SSI and SSI related Medicaid. Her mother retired and applied for Social Security retirement benefits. Her mother had high earnings, and Lauren’s payment as a CDB based on her mother’s work will be $800 per month.
What might happen to Lauren’s Medicaid in this situation? 19

20. More about Lauren
Since Lauren had no CDB payments before her mother retired, the State Medicaid Agency must exclude ALL of her CDB benefits when determining her eligibility for Special Medicaid.
If Lauren has other income or countable resources it might affect her eligibility for Special Medicaid. 20

21. Disabled Widow(er)s Benefits
In 1991, The Social Security Act was amended so that any former SSI eligible widow(er) will be considered by the state to be an SSI recipient for Medicaid purposes who:
would continue to be eligible for SSI benefits but for their DWB benefits and COLAs;
received an SSI benefit the month before their DWB payments began; and
is not yet entitled to Medicare Part A. Once Medicare Part A begins, the Special Medicaid Coverage ends. 21

22. Qualifying Period and DWB
When a former SSI recipient is found entitled to DWB benefits, all months on the SSI rolls at any time are credited concurrently against the 5-month disability waiting period and 24-month Medicare Qualifying Period (MQP). Due to this, Medicare coverage may begin with first month of DWB payments.
The State Medicaid Agency’s ability to exclude DWB when determining entitlement to Medicaid ends with entitlement to Medicare Part A. At this point, be sure to check for QMB/SLMB eligibility. 22

23. Other Income and Special Medicaid
Eligibility for special Medicaid benefits is strictly related to being “otherwise eligible for SSI or 1619(b)” once the applicable Title II exclusion has been made.
Eligibility for Special Medicaid depends entirely on how much of the title II benefit may be excluded, and on how much and what types of other income the beneficiary receives. 23

24. Income & Resource Rules
CMS requires states to use the same income/resource eligibility rules for SSI Medicaid and Special Medicaid.
Rules may differ from state to state (209b states in particular), but must be consistent between these programs. Know your state rules! 24

25. The Burning Question
How much can someone EARN and still retain eligibility for Special Medicaid? 25

26. 1619(b) and Special Medicaid
Individuals who meet the requirements for 1619(b) status are considered to be SSI eligible, simply not in cash payment status.
If a person would be eligible for either SSI or 1619(b) status after the applicable Title II disability payments (or portions of payments) are disregarded under Special Medicaid rules, Medicaid eligibility should be established. 26

27. Lauren Goes to Work
Lauren was getting SSI until her Mother retired and she became eligible for $800 of CDB each month. Lauren lost her SSI benefits but retained Medicaid as a Special Medicaid beneficiary because the State Medicaid Agency disregarded the entire CDB payment during the eligibility determination.
Lauren gets a job earning $1,000 a month 27

28. Lauren’s Countable Income for Medicaid Eligibility
STEP ONE:
Unearned Income (CDB) $
- General Income Exclusion (GIE) $
= Countable Unearned Income $
STEP TWO:
Gross Earned Income $
- SEIE $
= Remainder $
- GIE if not used above $
= Remainder $
- Earned Income Exclusion $
= Remainder $
- IRWE $
Divide by / 2
= Remainder $
- BWE $
= Total Countable Earned Income $
STEP THREE:
Countable Unearned Income $
+ Countable Earned Income $457.50
= Countable Income $457.50
- PASS $
= Total Countable Income $457.50
STEP FOUR:
Base SSI Rate: $
- Total Countable Income $
= Remainder $
Lauren would remain “otherwise eligible for SSI” since her countable income is less than the current FBR. Special Medicaid eligibility will continue.

29. Sofie Goes to Work
Sofie was getting $500 in CDB with $253 in SSI until her Dad died. Her CDB increased to $760 and she lost SSI eligibility but retained Medicaid as a Special Medicaid beneficiary.
Sofie is offered a job earning $900 per month. What will happen to her Special Medicaid eligibility? 29

30. Sofie’s Countable Income for Medicaid Eligibility
STEP ONE:
Unearned Income (CDB) $
- General Income Exclusion (GIE)$
= Countable Unearned Income $
STEP TWO:
Gross Earned Income $
- SEIE $
= Remainder $
- GIE if not used above $
- Earned Income Exclusion $
= Remainder $
- IRWE $
Divide by / 2
= Remainder $
- BWE $
= Total Countable Earned Income $
STEP THREE:
Countable Unearned Income $480.00
+ Countable Earned Income $417.50
= Countable Income $897.50
- PASS $
= Total Countable Income $897.50
STEP FOUR:
Base SSI Rate: $
- Total Countable Income $
= Remainder $
Sofie would remain “otherwise eligible for SSI” since her countable income is less than her state threshold amount and she meets all other requirements for 1619(b).

31. Factors to Consider
Is the individual a member of one of the three special protected classes?
How much of the individual’s title II benefit can be excluded?
Does the individual have other unearned income, including in-kind support?
What is the aged, blind and disabled income limit for individuals in your state including any applicable state supplements?
If the beneficiary is working, what is the threshold amount in your state?
Does the individual have excess resources? 31

32. Retaining Eligibility for Special Medicaid
Individuals who lose Special Medicaid entitlement due to other income may return to this status if income drops, and exclusion of appropriate title II would make the individual again eligible for Medicaid. This may occur at any time in the future.
Note: DWBs may not retain Special Medicaid status after Medicare coverage begins. 32

33. Challenges
In order to correctly determine Medicaid eligibility, the State must establish:
That the person lost SSI entitlement under one of these special circumstances;
The amount the individual was receiving in title II benefits before the SSI entitlement or 1619(b) was lost; and
Amounts and types of other income the individual receives at the time the decision is being made. 33

34. More Challenges
Individual involved may not know or understand that this exclusion might exist.
Medicaid worker also may not know about the Special Medicaid protections and thus does not apply the exclusion.
Medicaid workers often don’t understand 1619(b) status and how it applies to Special Medicaid beneficiaries.
The income exclusion rules are not always interpreted nor applied correctly. 34

35. The CWIC’s Role
Know your state Medicaid eligibility rules for SSI recipients – get the regulations!
Develop relationships within the agency that makes Medicaid eligibility determinations.
Recognize these special groups exist, and facilitate Medicaid entitlement if necessary.
Expect eligibility determination problems and work proactively to avoid them when possible. Educate beneficiaries on their appeal rights.
Refer to PABSS when necessary! 35