Apple Health for SSI-Related Individuals overview
Revised December 9, 2014
Purpose: To explain the general eligibility requirements for SSI-related individuals seeking Categorically Needy (CN) or Medically Needy (MN) health care coverage.
The SSI-Related eligibility requirements may be found in the following WACs:
- General requirements (WAC 182-512-0050 through WAC 182-512-0150)
- Resources (WAC 182-512-0200 through WAC 182-512-0550)
- Income, earned and unearned (WAC 182-512-0600 through WAC 182-512-0750)
- Income exclusions and disregards (WAC 182-512-0770 through WAC 182-512-0860)
- Special income disregards (WAC 182-512-0880)
- Income allocation and deeming (WAC 182-512-0900 through WAC 182-512-0960)
For related eligibility rules and other information:
- Definitions of terms used in discussing health care coverage, see WAC 182-500-0005.
- Medically Needy (MN) health care coverage, see WAC 182-519-0100.
- Supplemental Security Income (SSI), see chapter 388-474 WAC.
- Aged, Blind, or Disabled cash assistance, see WAC 388-449-0001.
- Long-Term Care, see chapters 182-513 WAC, 182-514 WAC and 182-515 WAC.
- Hospice Services, see chapter 182-551 WAC.
- Equal Access requirements, see WAC 182-503-0120.
SSI-related individuals may qualify for SSI-Related Apple Health, which offers both CN and MN health care coverage. CN coverage is the most comprehensive, covering more services than MN coverage. Eligibility for CN is determined first and eligibility for MN or other programs is determined only if the individual is not eligible for CN.
SSI-related individuals 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, such as:
- Aged, blind, or disabled adults who are not receiving SSI cash benefits, including;
- 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 individuals with gross monthly earnings at or above substantial gainful activity (SGA).
- 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 Apple Health coverage provided under sections 1619(a) and (b) of the Social Security Act), unless the individual continues to receive a Title 2 cash benefit, e.g. SSDI or DAC.
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.
- Children who are blind or disabled and who are not receiving SSI cash benefits (See WAC 182-505-0210); and
- Certain qualified aliens who meet the nonimmigration status criteria for SSI-related medical (See WAC 182-508-0001).
The Agency uses the Federal SSI cash assistance rules when determining eligibility for SSI-related medical, with a few exceptions that provide less restrictive rules. For more comprehensive definitions of blind and disabled, see SSA Program Operating Manual Systems (POMS) @ SI 00501.001 Eligibility Under the Supplemental Security Income Provisions.
- An individual 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 individual 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 coverage group during the SSA determination and appeal process.
The Division of Disability Determination Services (DDDS) processes referrals for blindness or disability determinations. See "Worker Responsibilities" after WAC 182-512-0150.
Individuals who receive a cash grant under the Aged, Blind, Disabled cash program and meet SSI criteria for disability, income and resources, may receive health care coverage under the following programs while their SSI application is pending with the Social Security Administration (SSA):
- Apple Health for Adults (typically if the individual is a citizen or a Qualified Alien who has met the 5-year bar); or
- Apple Health Medical Care Services (typically if the individual is a Qualified Alien who has not met the 5-year bar or a Non Qualified Alien).
Note: The following apply to individuals enrolled in Healthcare for Workers with Disabilities (HWD):
- An eligible individual may choose to enroll in HWD with gross monthly earnings above or below the substantial gainful activity (SGA) level. If an individual 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.
- 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.
- 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.
- When SSA terminates an individual’s SSI cash payment, but is determining 1619(a) or 1619(b) eligibility for that individual, continue the individual on S01 medical until you receive additional information on the SDX referring the individual back to the State for a Medicaid determination (R on the medical eligibility field on SDX1).
- While the individual 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.
- When SSA terminates the individual’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.
- To be an SSI-related individual, the individual must be age 65 or older or determined blind or disabled by either the federal SSI/SSA program or by DDDS. An individual who is only receiving disability benefits such as VA, L&I, Railroad Retirement Benefits (RRB), etc., is not necessarily an SSI-related individual. For a disability determination, initiate a Non-Grant Medical Assistance (NGMA) referral.
- The Categorically Needy (CN) program provides a federal-funded Apple Health benefit for certain individuals with income below Categorically Needy (CN) standards. SSI-related CN standards are described in WAC 182-512-0010.
- An individual who is eligible for an SSI cash grant and chooses not to accept it is still eligible for CN medical as an SSI-related individual.
- Sometimes an SSI recipient stops receiving the SSI cash grant because he or she is working. He or she will still be eligible for CN medical under the S01 program under Section 1619(a) and/or (b) if there is a "C" Medical Eligibility Code on the SDX screen in ACES.
- The "ineligible spouse" of an SSI recipient (i.e., a spouse who does not receive SSI in his or her own right but who is included in the SSI recipient's benefits) is not considered an SSI recipient for purposes of SSI-related medical.
- The spouse must apply for health care coverage and have SSI-related eligibility determined separately.
- An SSI-ineligible spouse cannot receive noninstitutional CN coverage, but may qualify for medically needy (MN) coverage.
- Eligibility re-determinations must be completed on each individual in the AU for all possible health care programs before terminating CN coverage and before denying an application.
- The Medically Needy (MN) program provides a federal and state-funded Apple Health benefit for individuals with income above Categorically Needy (CN) standards. MN standards are described in WAC 182-519-0050. MN provides slightly less medical coverage than CN. See Scope of Care for which services are covered by CN and MN.
- For MN individuals with spenddown, the certification period starts either:
- The first of the certification period if the individual 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 HCA/DSHS medical programs or prescription expenses (non-Medicare Part D expenses). See Certification Periods, chapter 182-504 WAC.
- There is no automatic re-determination process for MN at the end of a certification period. An individual must apply for each certification period.
- Make sure a new application is mailed to the individual before the end of the base period, especially if the review has fallen out of the ACES review cycle or if the individual moved.
- The 3-month retroactive period of eligibility does not require a separate application.
- For reported changes that will alter the spenddown amount:
- If the individual 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 individual eligible for CN coverage, make those changes for the appropriate months. Be sure to send an award letter explaining the changes.
- If the individual has not met spenddown, recalculate the spenddown using current information and notify the individual of the changes. See the Change of Circumstances of the Spenddown chapter of the manual.
- Allow an individual 30 days after the base period has expired to send in bills to meet spenddown. It may take this long for the individual to gather medical bills. If the individual requests more time to send bills in, allow it. If a fair hearing is filed, allow the individual to continue submitting bills incurred during the established base period until the fair hearing is resolved.
Referral Process to Division of Disability Determination Services (DDDS):
In Washington State, DDDS makes the blindness and disability determinations for both:
- Social Security Administration (Social Security disability benefits and SSI cash grant); and
- SSI-related individuals who:
- Do not receive SSI or SSA disability;
- Need a re-examination for continuing eligibility;
- Were terminated from SSI due to no longer meeting disability criteria;
- Meet SSI-related income and resource standards; or
- Have gross monthly earnings at or above the current substantial gainful activity (SGA) level (See SSA "Substantial Gainful Activity - Amounts"). For more information about SGA, see the SSA Red Book.
- If an individual is currently receiving SSI or SSA disability, DDDS has already determined that the individual is blind or disabled.
Worker Responsibilities for Disability Determinations
- When a blindness or disability determination is needed:
- For the individual 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 800-871-9275.
- For all individuals who have gross monthly earnings below SGA, follow local procedures for completing the NGMA process at the local office.
- 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 individual 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 individual meets the disability criteria, open the appropriate Apple Health program 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 individual does not meet the disability criteria, consider the individual for all other health care programs or allow the individual to provide new medical information to be forwarded to DDDS for reconsideration.
- See Fair Hearing chapter (Chapter 388-02 WAC or Chapter 182-526 WAC) for fair hearing and reconsideration procedures.