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:

For related eligibility rules and other information:

WAC 182-512-0050 SSI-related medical -- General information.

Effective April 14, 2014.

  1. The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) 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:
    1. Age sixty-five or older;
    2. Blind with:
      1. Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
      2. A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.
    3. Disabled:
      1. "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
        1. Can be expected to result in death; or
        2. Has lasted or can be expected to last for a continuous period of not less than twelve months; or
        3. 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.
      2. Decisions on SSI-related disability are subject to the authority of:
        1. Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and
        2. Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
  2. 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 agency unless the applicant's:
    1. Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
    2. Medical condition has changed since the SSA denial was issued.
  3. The agency considers a person 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 person is eligible for WAH CN health care coverage under WAC 182-510-0001.
  4. Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:
    1. For all programs:
      1. WAC 182-506-0015, Medical assistance units;
      2. WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;
      3. Program specific requirements in chapter 182-512 WAC;
      4. WAC 182-503-0050, Verification;
      5. WAC 182-503-0505, General eligibility requirements for medical programs;
      6. WAC 182-503-0540, Assignment of rights and cooperation;
      7. Chapter 182-516 WAC, Trusts, annuities and life estates.
    2. For LTC programs:
      1. Chapter 182-513 WAC, Long-term care services;
      2. Chapter 182-515 WAC, Waiver services.
    3. For WAH MN, chapter 182-519 WAC, Spenddown;
    4. For WAH HWD, program specific requirements in chapter 182-511 WAC.
  5. Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.
  6. The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.
  7. The agency 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 savings programs unless the agency adopts rules that are less restrictive than those of the SSI program.
  8. Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

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):

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.

Worker Responsibility

  1. 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).
    1. 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.
    2. After the SSA sends the final decision on the SDX record, determine eligibility for any appropriate programs based on the SSA decision.
  2. 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.
  3. 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.

WAC 182-512-0100 SSI-related medical -- Categorically needy (CN) medical eligibility.

Effective April 14, 2014.

  1. Washington apple health (WAH) categorically needy (CN) coverage is available for an SSI-related person who meets the criteria in WAC 182-512-0050, SSI-related medical—General information.
  2. To be eligible for SSI-related WAH CN medical programs, a person must also have:
    1. Countable income and resources at or below the SSI-related WAH CN medical monthly standard (refer to WAC 182-512-0010) or be eligible for an SSI cash grant but choose not to receive it; or
    2. Countable resources at or below the SSI resource standard and income above the SSI-related WAH CN medical monthly standard, but the countable income falls below that standard after applying special income disregards as described in WAC 182-512-0880; or
    3. Met requirements for long-term care (LTC) WAH CN income and resource requirements that are found in chapters 182-513 and 182-515 WAC if wanting LTC or waiver services.
  3. An ineligible spouse of an SSI recipient is not eligible for noninstitutional SSI-related WAH CN health care coverage. If an ineligible spouse of an SSI recipient has dependent children in the home, eligibility may be determined for health care coverage under the WAH medically needy program or for a modified adjusted gross income-based program.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

  1. 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.
  2. 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.
  3. 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.
  4. 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.
    1. The spouse must apply for health care coverage and have SSI-related eligibility determined separately.
    2. An SSI-ineligible spouse cannot receive noninstitutional CN coverage, but may qualify for medically needy (MN) coverage.
  5. 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.

WAC 182-512-0150 SSI-related medical -- Medically needy (MN) medical eligibility.

Effective April 14, 2014.

  1. Washington apple health (WAH) medically needy (MN) health care coverage is available for any of the following:
    1. A person who is SSI-related and not eligible for WAH categorically needy (CN) medical coverage because the person has countable income that is above the WAH CN income level (CNIL) (or for long-term care (LTC) recipients, above the special income limit (SIL)):
      1. The person's countable income is at or below WAH MN standards, leaving no spenddown requirement; or
      2. The person's countable income is above WAH MN standards requiring the person to spenddown their excess income (see subsection (4) of this section). See WAC 182-512-0500 through 182-512-0800 for rules on determining countable income, and WAC 182-519-0050 for program standards or chapter 182-513 WAC for institutional standards.
    2. An SSI-related ineligible spouse of an SSI recipient;
    3. A person who meets SSI program criteria but is not eligible for the SSI cash grant due to immigration status or sponsor deeming. See WAC 182-503-0535 for limits on eligibility for aliens;
    4. A person who meets the WAH MN LTC services requirements of chapter 182-513 WAC;
    5. A person who lives in an alternate living facility and meets the requirements of WAC 182-513-1305; or
    6. A person who meets resource requirements as described in chapter 182-512 WAC, elects and is certified for hospice services per chapter 182-551 WAC.
  2. A person whose countable resources are above the SSI resource standards is not eligible for WAH MN noninstitutional health care coverage. See WAC 182-512-0200 through 182-512-0550 to determine countable resources.
  3. A person who qualifies for services under WAH long-term care programs has different criteria and may spend down excess resources to become eligible for WAH LTC institutional or waiver health care coverage. Refer to WAC 182-513-1315 and 182-513-1395.
  4. A person with income over the effective WAH MN income limit (MNIL) described in WAC 182-519-0050 may become eligible for WAH MN coverage when the person has incurred medical expenses that are equal to the excess income. This is the process of meeting spenddown. Refer to chapter 182-519 WAC for spenddown information.
  5. A person may be eligible for health care coverage for any or all of the three months immediately prior to the month of application, if the person has:
    1. Met all eligibility requirements for the months being considered; and
    2. Received medical services covered by medicaid during that time.
  6. A person who is eligible for WAH MN without a spenddown is certified for up to twelve months. For a person who must meet a spenddown, refer to WAC 182-519-0110. For a person who is eligible for a WAH long-term care MN program, refer to WAC 182-513-1305 and 182-513-1315.
  7. A person must reapply for each certification period. There is no continuous eligibility for WAH MN.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

  1. 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.
  2. For MN individuals with spenddown, the certification period starts either:
    1. 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
    2. 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.
  3. There is no automatic re-determination process for MN at the end of a certification period. An individual must apply for each certification period.

Worker Responsibilities

  1. 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.
  2. The 3-month retroactive period of eligibility does not require a separate application.
  3. For reported changes that will alter the spenddown amount:
    1. 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.
    2. 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.
  4. 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:

  1. Social Security Administration (Social Security disability benefits and SSI cash grant); and
  2. SSI-related individuals who:
    1. Do not receive SSI or SSA disability;
    2. Need a re-examination for continuing eligibility;
    3. Were terminated from SSI due to no longer meeting disability criteria;
    4. Meet SSI-related income and resource standards; or
    5. 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.
  3. 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

  1. When a blindness or disability determination is needed:
    1. 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.
    2. For all individuals who have gross monthly earnings below SGA, follow local procedures for completing the NGMA process at the local office.
    3. 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.
    4. Request retroactive approval if the individual had a medical need in any of the three months before the month of application.
    5. 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.
  2. When DDDS returns the disability determination:
    1. 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.
    2. 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.
  3. See Fair Hearing chapter (Chapter 388-02 WAC or Chapter 182-526 WAC) for fair hearing and reconsideration procedures.

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