SSI-related Medicaid overview

Revised date
Purpose statement

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.

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.

If an individual is under age 65 and doesn't have Medicare, review their eligibility for MAGI-based coverage before looking at SSI-related medical.

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 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 Health Care 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 II cash benefit, e.g. SSDI or DAC.

Note: Individuals receiving Title II 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 II 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) at 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" in the NGMA overview.

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 Health Care 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

  • 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.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

WAC 182-512-0010 Supplemental security income (SSI) standards, SSI-related categorically needy income level (CNIL), and countable resource standards.

Effective January 27, 2019

  1. The SSI payment standards, also known as the federal benefit rate (FBR), change each January 1st.
  2. See WAC 388-478-0055 for the amount of the state supplemental payments (SSP) for SSI recipients.
  3. See WAC 182-513-1205 for standards of clients living in an alternate living facility.
  4. The SSI-related CNIL standards are the same as the SSI payment standards for single persons and couples. Those paying out shelter costs have a higher standard than people who have supplied shelter.
  5. The countable resource standards for SSI and SSI-related CN medical programs are:
    1. One person $2,000
    2. A legally married couple $3,000

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

  • 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 redeterminations must be completed on each individual in the AU for all possible health care programs, including MAGI coverage, before terminating CN coverage and before denying an application.

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

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

Effective June 26, 2022.

  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 182-513-1205; 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 12 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 182-513-1395 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

  • 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 redetermination process for MN at the end of a certification period. An individual must apply for each certification period.

Worker responsibilities

  • 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.
  • When a blindness or disability determination is needed, follow instructions described in the NGMA overview.

WAC 182-512-0350 SSI-related medical -- Property and contracts excluded as resources.

WAC 182-512-0350 SSI-related medical -- Property and contracts excluded as resources.

Effective November 14, 2019.

  1. The agency excludes the following resources when determining eligibility for SSI-related medical assistance:
    1. A client's household goods and personal effects;
    2. One home (which can be any shelter), including the land on which the dwelling is located, and all contiguous property and related out-buildings in which the client has ownership interest for long-term care programs, see WAC 182-513-1350 for home equity limits, when:
      1. The client uses the home as a primary residence;
      2. The client's spouse lives in the home;
      3. The client does not currently live in the home, but the client or the client's representative has stated the client intends to return to the home; or
      4. A relative, who is financially or medically dependent on the client, lives in the home and either the dependency is documented or a written statement of dependency is provided by the client, the client's authorized representative, or by the client's dependent relative.
    3. The value of ownership interest in jointly owned real property is an excluded resource for as long as sale of the property would cause undue hardship to a co-owner due to loss of housing. Undue hardship would result if the co-owner:
      1. Uses the property as the client's principal place of residence;
      2. Would have to move if the property were sold; and
      3. Has no other readily available housing.
  2. Proceeds from the sale of an interest described in subsection (1)(b) of this section, are excluded as a resource if the client uses the proceeds to purchase another home by the end of the third month after receiving the proceeds from the sale.
  3. An installment contract from the sale of the home described in subsection (1)(b) above is not a resource as long as the client plans to use the entire down payment and the entire principal portion of a given installment payment to buy another excluded home, and does so within three months after the month of receiving such down payment or installment payment.
  4. The value of sales contracts is excluded when the:
    1. Current market value of the contract is zero;
    2. Contract cannot be sold; or
    3. Current market value of the sales contract combined with other resources does not exceed the resource limits.
  5. Sales contracts executed before December 1, 1993, are excluded resources as long as they are not transferred to someone other than a spouse.
  6. A sales contract for the sale of the client's principal place of residence executed between December 1, 1993, and May 31, 2004, is an excluded resource unless it has been transferred to someone other than a spouse and it:
    1. Provides interest income within the prevailing interest rate at the time of the sale;
    2. Requires the repayment of a principal amount equal to the fair market value of the property; and
    3. The term of the contract does not exceed thirty years.
  7. A sales contract executed on or after June 1, 2004, on a home that was the principal place of residence for the client at the time of institutionalization is an excluded resource as long as it is not transferred to someone other than a spouse and it:
    1. Provides interest income within the prevailing interest rate at the time of the sale;
    2. Requires the repayment of a principal amount equal to the fair market value of the property within the anticipated life expectancy of the client; and
    3. The term of the contract does not exceed thirty years.
  8. Payments received on sales contracts of the home described in subsection (1)(b) of this section are treated as follows:
    1. The interest portion of the payment is treated as unearned income in the month of receipt of the payment;
    2. The principal portion of the payment is treated as an excluded resource if reinvested in the purchase of a new home within three months after the month of receipt;
    3. If the principal portion of the payment is not reinvested in the purchase of a new home within three months after the month of receipt, that portion of the payment is a liquid resource as of the date of receipt.
  9. Payments received on sales contracts described in subsection (4) of this section are treated as follows:
    1. The principal portion of the payment on the contract is treated as a resource and counted toward the resource limit to the extent retained at the first moment of the month following the month of receipt of the payment; and
    2. The interest portion is treated as unearned income the month of receipt of the payment.
  10. For sales contracts that meet the criteria in subsection (5), (6), or (7) of this section but do not meet the criteria in subsection (3) or (4) of this section, both the principal and interest portions of the payment are treated as unearned income in the month of receipt.
  11. Property essential to self-support (PESS) is excluded as a resource within certain limits. There are three categories of PESS:
    1. Real and personal property used in a trade or business:
      1. That is a resource defined under WAC 182-512-0200;
      2. That is in current use as described under the Social Security Administration's Program Operations Manual System (POMS) SI 01130.504; and
      3. Where the trade or business is a sole proprietorship or simple partnership.
    2. Nonbusiness income-producing property (i.e., property not used in a trade or business), such as:
      1. Houses or apartments for rent; and
      2. Land, other than home property.
    3. Property used to produce goods or services essential to a client's daily activities, such as land used to produce vegetables or livestock, which is used only for personal consumption in the client's household. This includes personal property necessary to perform daily functions including vehicles such as boats for subsistence fishing and garden tractors for subsistence farming, but does not include other vehicles such as those that qualify as automobiles (e.g., cars, trucks).
  12. The agency excludes a client's real and personal property used in a trade or business, described under subsection (11)(a) of this section, regardless of value as long as it is in current use (as described under POMS SI 01130.504) in the trade or business and remains used in the trade or business.
  13. The agency excludes up to $6,000 of a client's equity in nonbusiness income-producing property, described under subsection (11)(b) of this section, if it produces a net annual income to the client of at least six percent of the excluded equity.
    1. If a client's equity in the property is over $6,000, only the amount over $6,000 is counted toward the resource limit, as long as the net annual income requirement of six percent is met on the excluded equity.
    2. If the six percent requirement is not met due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the activities will again meet the six percent rule, the same exclusions as in subsection (13)(a) of this section apply.
    3. If a client has more than one piece of real property in this category, each is independently evaluated to see if it meets the six percent return, and the total equities of all those properties are added to see if the total is over $6,000. If the total is over the $6,000 limit, the amount exceeding the limit is counted toward the resource limit.
    4. The equity in each property that does not meet the six percent annual net income limit is counted toward the resource limit, with the exception of property that represents the authority granted by a governmental agency to engage in an income-producing activity if it is:
      1. Used in a trade or business or nonbusiness income-producing activity; or
      2. Not used due to circumstances beyond the client's control (e.g., illness), and there is a reasonable expectation that the use will resume.
  14. Property used to produce goods or services essential to a client's daily activities is excluded if the client's equity in the property does not exceed $6,000.
  15. Personal property used by a client as an employee for work is not counted toward the resource limit, regardless of value, while in current use (as described under POMS SI 01130.504), or if the required use for work is reasonably expected to resume.
  16. Interests in trust or in restricted Indian land owned by a client who is of Indian descent from a federally recognized Indian tribe or held by the spouse or widow/er of that client, is not counted toward the resource limit if permission of the other people, the tribe, or an agency of the federal government must be received in order to dispose of the land.
  17. Receipt of money by a member of a federally recognized tribe from exercising federally protected rights or extraction of excluded resources, such as fishing, shell-fishing, or selling timber from protected land, is considered conversion of an excluded resource during the month of receipt. Any amount remaining from the conversion of this excluded resource on the first of the month after the month of receipt will remain excluded if it is used to purchase another excluded resource. Any amount remaining in the form of a countable resource (such as in a checking or savings account) on the first of the month after receipt, will be added to other countable resources for eligibility determinations.

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.

(11) (a) (iii) Where the trade or business is a sole proprietorship or simple partnership.

The WAC refers to a specific type of trade or business as a category where Property Essential for Self-Support (PESS) can be excluded as a resource.

Individuals who consider themselves a Limited Liability Corporation (LLC) and file taxes as a simple partnership using IRS Form 1065 along with a Schedule C form, are considered a simple or sole partnership and meet the PESS trade or business requirements.

The Social Security Administration's (SSA) Program Operations Manual System, (POMS) explains how the SSA documents verification of a Social Security (SS) beneficiary's trade or business for the use of PESS in POMS SI 01130.501C.3. POMS does not list specific business structures that qualify to use PESS. Instead, it references IRS tax return forms that are evidence someone has a trade or business for PESS purposes.

Referral process to Division of Disability Determination Services (DDDS)

In Washington State, DDDS makes both the blindness and disability determinations:

  • 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 ss 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.
  • When a blindness or disability determination is needed, follow instructions described in the NGMA overview.

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