2635 Persons with Drug Addiction or Alcoholism - Based on the drug addiction and alcoholism provisions of the SSI program, SSI benefits are not available to individuals whose drug addiction or alcoholism is a contributing factor to the determination of disability (i.e., would not be found disabled if the drug abuse and/or alcohol abuse were to stop). These provisions became effective as of March 29, 1996. Medical eligibility under the SI or MS program shall not be provided in such instances. However, SSI beneficiaries whose benefits are terminated due to these provisions and who are medical recipients shall continue to be eligible for Medicaid if they timely appeal the SSI decision and are otherwise eligible except for the disability determination. Such eligibility continues throughout the appeal process. Verification from SSA that the appeal was filed timely is required.
2636 Loss of Recipient Status - When an individual loses SSI recipient status due to an action taken by SSA to suspend, stop payment or terminate benefits, the following provisions apply.
If the individual timely appeals the SSI eligibility decision by SSA to suspend, stop payment or terminate benefits, SSI recipient status continues. The appeal is timely if filed within 60 days of notification of the SSA action. If the appeal is filed within 10-days of the notification, the recipient can choose to continue SSI benefits throughout the entire appeal process (disability related action) or through the first level of appeal (non-disability related action. The recipient shall continue to be eligible for SI medical assistance (if otherwise eligible) throughout the appeal process. Verification from SSA that the appeal was timely filed is required.
If the individual does not appeal the SSA decision to suspend, stop payment or terminate SSI benefits, or the decision is no longer under appeal, SI medical assistance shall continue while eligibility under another medical assistance program (if any) is determined. Once that determination is complete, SI medical assistance shall be discontinued giving timely and adequate notice. Continued SI medical assistance provided pending the eligibility determination in most instances is not considered overstated eligibility subject to a claim. See 11121.1 (5) and 11122 (7).
In addition, there may be instances where the suspension or stop payment of SSI benefits is temporary. If contact with SSA verifies that benefits will be reinstated within the next two months, SI medical assistance may continue. Otherwise, eligibility under another medical assistance program must be determined as indicated above. See Policy Memo 2018-10-01, re: SSI Termination and Verification of Resources for further guidance.
NOTE: If the agency has information that the SSI recipient has resources, including income, which the SSA verifies will make the individual ineligible for SSI, EATSS SDX information will be disregarded, and the individual would no longer be considered an SSI recipient. The process to determine eligibility under another medical assistance program described above would apply.
2637 Effect of Institutionalization - When an SSI recipient enters an institution the following provisions apply.
An SSI recipient who enters an institution for a temporary (short term) stay (see 8113) will continue to receive SSI benefits. SSI recipient status continues. An SSI recipient who enters a medical institution for a long term stay in which Medicaid will pay for all or a portion of their care will be limited to a maximum $30/month SSI benefit for each full month in the institution. As a result, some individuals may lose their SSI benefit while institutionalized if their countable income exceeds $30/month. SSI recipient status would cease for those who lose their SSI benefit. Continued eligibility for those losing SSI recipient status shall be determined as described in 2636.
NOTE: An individual age 21 to 64 residing in a mental health nursing home will continue to receive unreduced SSI benefits because Medicaid will not pay for their care in the facility. The full amount of the SSI benefit, and any other countable income, shall be budgeted in determining the monthly patient liability. See 8112.4 (2).
There is no SSI eligibility for individuals who reside in most public institutions such as prisons or other correctional facilities (see 8111), unless it is a medical facility for which Medicaid payments can be provided, such as the state psychiatric (except for residents age 21 to 64) and intellectual disability hospitals. SSI payments may be reinstated to these individuals once they return to the community. This provision does not apply to SSI recipients who are in the institution less than a full calendar month.
SSI recipients in a Medicaid approved institution for a long term stay may have a patient liability if income exceeds the $62/month protected income level beginning with the month following the month of entrance (see 8172). SSA may continue SSI benefits for up to 3 months following the month of entrance (2 months for 1619 eligibles). Those SSI payments shall be disregarded in determining the patient liability if long term stay budgeting is being applied. Any other countable income shall be included in the determination.
NOTE: The transfer of property provisions apply to an individual who retains SSI recipient status while institutionalized. See 5720.1
2638 Protected Filing Date - If an individual makes application for medical and has been or is later denied disability status under the SSI program, there is no eligibility for automatic status and, unless the individual otherwise qualifies for another FFP medical program, the application shall be denied. However, if the individual requests reconsideration of the disability decision or formally appeals the SSI decision within the allowable SSA reconsideration/appeal period, the medical application date shall be protected for purposes of eligibility (including prior eligibility). Verification of the timely request or appeal must be documented. If the client obtains disability status upon reconsideration or wins the SSI appeal and reapplies for medical, automatic eligibility shall be provided back to the protected medical application date, including the 3 prior months, provided that the individual is determined eligible for SSI for this entire time period.
2639 Special Provisions for Children Terminated from SSI Due to Changes in Disability Criteria - Based on the provisions of the Budget Reconciliation Act of 1997, children who lose eligibility for SSI benefits due to changes in the SSI childhood disability criteria resulting from the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) shall continue to be eligible for medical assistance as long as they would be otherwise eligible for SSI except for the loss of disability status. See also 2636 regarding children whose termination of benefits is timely appealed. This group of children is limited to those receiving SSI benefits as of August 22, 1996, including those who have been receiving SSI in another state and subsequently move to Kansas. Documentation of SSI termination due to the new disability criteria is required as well as verification that the individual was receiving SSI on August 22, 1996. The Social Security Administration provides periodic lists of individuals who no longer meet disability criteria under these provisions.
In order to continue medical coverage under this provision, the general eligibility requirements of cooperation and residency contained in 2100 must be met. In addition, financial eligibility must be redetermined on a yearly basis. This can be accomplished in one of two ways. First, a Medicaid poverty level determination in accordance with the Kansas Family Medical Assistance Manual is to be done and children meeting this criteria set up under the Poverty level program. If the child does not meet the financial criteria for Poverty level program, falls into CHIP or loses poverty level coverage, an SSI financial determination is to be done. Countable resources of the custodial parent(s) and the child must be below the appropriate resource standard per 5130. Countable income shall be determined through use of the electronic SSI eligibility worksheet. The income of the custodial parents (including any stepparents) and the child, and any of the child's natural or adoptive siblings is to be considered on this worksheet. If the countable income obtained is less than current one-person SSI beneficiary level, the child remains eligible. Procedures set forth in Policy Memo 1999-09-01, re: Self-Employment, Assistance Planning, Adding Child to Plan, Newborns, Retroactive Coverage, IM-3160 Revision, Policy Memos regarding ex parte redeterminations shall be utilized to the extent possible when completing the financial determination.
Coverage under this provision is available through the month the child turns age 18. Continued medical eligibility after this time would then have to be determined under other existing categories (e.g., MS if person meets adult disability criteria).