SSI deemed eligible

Revised date

Note: 1619b clients are considered the same as an individual receiving SSI. Eligibility for Medicaid is continued based on SDX information to continue Medicaid due to 1619b status.

Deemed SSI eligible clients are usually under the S02 medical coverage group. They would have continued to be eligible for SSI except their SSI was closed by disabled adult child (DAC), Cost of living adjustment (COLA aka Pickle) or Widowers benefits.

1619B and "Deemed SSI eligible" clients

  • SSI deemed eligible clients (countable income is under the SSI standard after DAC, Pickle/COLA exclusion AND SSI was closed due to the receipt of DAC, benefits, widowers benefits, or COLA) do not pay service participation. They DO pay for room and board in an assisted living facility (ALF).
  • 1619b clients are considered the same as an "SSI client" SSI payments have stopped due to earnings. SDX coding indicates to continue Medicaid on SDX 1 in the Med Elig field. 1619b clients do not pay service participation. They DO pay room and board in an ALF.

Deemed SSI eligible clients. What does that mean?

Clients who have countable income under the SSI standard after subtracting:

  • Disabled Adult Child (DAC) benefits;
  • Pickle/COLA; 
  • Widow/Widowers; AND
  • their SSI was closed because of the receipt of the DAC/COLA/Widow(er) income.

These exclusions are described in WAC 182-512-0880. Clients continue to receive CN Medicaid as long as they meet resource criteria.

  • Not every client receiving DAC or Widower income is eligible for this exclusion.
  • DAC clients with countable income under the SSI standards are often called "Protected DAC" individuals.
  • DAC clients with countable income over the SSI standard are not "protected DAC".
  • Deemed SSI eligible clients do NOT pay HCB Waiver service participation, but they do pay room and board if living in an ALF.
  • Deemed SSI eligible clients DO participate toward the cost of care when living in a medical institution.
  • If countable income is over the SSI standard after the exclusion, then all income is counted in post eligibility in determining participation including DAC income.

In other words, an individual who would be eligible for CN/S02 in ACES

A client who would otherwise qualify for S02/CN SSI-related Medicaid because their countable income is at or below the SSI standard does not participate towards personal care under the Waiver program, but they are responsible to pay room and board when living in an ALF.

These clients do need to meet the same criteria for long-term care services as other Waiver clients and may be subject to transfer of an asset penalty or excess home equity described in WAC 182-513-1350

Let the SW/Case manager know if client would be eligible for a non institutional CN program so Medicaid Personal Care (MPC) can be considered. MPC is considered a priority over the HCB Waiver program.

1619b status, what does it mean?

SSI clients whose earnings put them over the SSI cash benefit standard, but Social Security continues their SSI eligibility. They are considered an SSI recipient and continue to send in reviews to Social Security. The SDX indicates continued Medicaid when a client is 1619b. 1619b clients do not pay service participation because they are considered to be an SSI client. Clients would pay the ALTSA room and board amount if residing in an ALF. Clients can have GROSS income over the special income level (SIL) and continue to receive HCB Waiver as long as Social Security maintains their 1619b status.

What happens if a client loses their protected DAC status?

  • ACES is programmed to do the COLA, DAC, Widower disregard correctly as long as the SSI end date and the correct coding is indicated on the unearned income screen.
  • If a client on MPC loses protected DAC status and it is because of earnings, refer to the HWD specialist for a determination. Active HWD recipients can receive either MPC or HCB Waiver services if functionally eligible. The case-manager makes the decision as to the type of services the client will receive.
  • If a client on MPC at home loses protected DAC status and it is not due to earnings, send a referral to the client case-manager to see if the client is functionally eligible for a HCB Waiver as the client is no longer eligible to receive a noninstitutional CN program. If the client is in a residential setting, consider eligibility for G03.
  • If a client on MPC loses protected DAC status and is no longer eligible for non institutional CN Medicaid and is on DDA MPC services, request that the DDA case-manager coordinate a referral to HCS intake to look at the COPES waiver. (DDA may not have an available slot on the DDA Waiver). It is the responsibility of the DDA case-manager to coordinate with HCS in this scenario. 
  • If a client on HCB Waiver loses protected DAC status, they may be responsible to pay participation toward the cost of care. Once a client loses protected DAC status, all the income including the DAC income is counted in determining if there is a client responsibility toward the cost of care.

Example #1

S02/MPC client. Receives $850 SSDI under their own claim. Receives $600 DAC benefit. Per WAC 182-512-0880, client fits the criteria for the DAC exclusion.

$1450 total income
- $600 DAC exclusion
- $20 disregard
= $830 countable income.

Countable income is under the CNIL standard, so they are considered a protected DAC.

This client is not responsible to pay participation toward the cost of personal care even if switched over to a HCB Waiver service. The client is responsible to pay the ALTSA room and board rate if living in an alternate living facility (ALF).

Example #2

S02/MPC client receives $600 SSDI under their own claim. Receives $600 DAC benefit. Per WAC 182-512-0880, client fits the criteria for the DAC exclusion. The countable income after the DAC exclusion is under the CNIL standard. Client is considered a protected DAC.

Client starts working and has $1000 earnings.

$2,200 total income
- $600 DAC exclusion
- 20 disregard
- $465.50 (65 and 1/2 earned income deduction)
= $1,114.50 countable income. Income is over the CNIL income standard. No longer eligible for CN non institutional.

Redetermination of Medicaid needed. All the income, including the DAC income will be used in eligibility and post eligibility if on a L22 medical coverage group as client is no longer considered a "Protected DAC". This client is no longer a protected DAC because the countable income is over the CNIL standard.

  • Refer to the HWD specialist for a determination of HWD. The HWD premium is no more than 7.5% of the total monthly income. All income including the DAC income is used in eligibility and premium determination.
  • HWD is preferable over HCS HCB Waiver as the premium cost is less than projected participation.
  • If a DDA client, the gross income is over the Medicaid SIL, therefore HWD is the only option for services.
  • Continue Medicaid until the HWD specialist has made the determination. 
  • Notify the case manager that client appears HWD-eligible and has been referred to the HWD specialist.
  • Notify the case manager they can be considered for either MPC or HCB Waiver.
  • If the client is in a residential setting, they will be responsible to pay the ADSA room and board rate to the provider.

Example #3

Client receives $1000 DAC income and is on DDA Waiver in a residential setting. Client is eligible to receive the DAC exclusion described in WAC 182-512-0880 and does not pay participation toward the cost of care because the countable income (-0-) is under the CNIL. The client is responsible to pay the ALTSA room and board rate to the residential provider.

Client starts receiving a $800 monthly pension benefit from a deceased parent's retirement annuity. The countable income is now over the CNIL. No longer a protected DAC. This client will now be responsible to pay Waiver participation plus the ALTSA room and board rate to the residential provider. The client will be allowed to keep $62.79 Personal Needs Allowance (PNA).

Example #4

Same scenario as example #3 except the client is on MPC services rather than DDA Waiver.

Consider G03 described in WAC 182-513-1205 when doing the redetermination as client is no longer eligible for a S02 and is living in a residential setting.

Example #5

Same scenario as example #3 except the client is on MPC services authorized by DDA and living at home.

In this scenario, the client no longer qualifies for MPC because the client is no longer eligible for non institutional CN Medicaid.

Send a referral to the DDA case manager indicating the client is no longer eligible for MPC and a HCB Waiver needs to be considered if the client is need of services. This may take coordination by the DDA case manager and HCS intake for COPES if DDA Waiver cannot be considered.

Continue the Medicaid while a determination is being considered and set a barcode tickler to check status in 30 days.

Example #6

Client receives $1200 DAC benefit and is on HCS COPES Waiver. Client was never on SSI in the past, so does not qualify for DAC exclusion per WAC 182-512-0880, Client is not considered a protected DAC.

All the DAC income is counted in initial and post eligibility.

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