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.
- 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.
- 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 reexamination 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 redetermination to the Social Worker at least 90 days prior to the review end date. If the reexam 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.