The following groups of individuals may qualify for medical assistance without a spenddown (or without a liability in the HCBS program) except for persons convicted of medical fraud or who have a special spenddown. (See 11221.3 and 11126.1 (3).) The appropriate criteria established below must be met.
Based on a March 1984 District Court decision, persons who have lost their SSI eligibility (including eligibility under section 1619 per 2634) may qualify for medical assistance without a spenddown if they meet the following criteria:
Those persons who lose their SSI eligibility due solely to an OASDI cost-of-living increase will qualify based on the provisions above. This provision is not applicable to those who (1) currently receive SSI or cash assistance, or (2) who reside in a nursing facility or state institution. In addition, an individual who was terminated from SSI because he or she was awarded initial OASDI benefits will not be eligible because there was never concurrent eligibility for both programs in the same month.
Qualifying individuals must meet all Medically Needy nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections. The one person allowable nonexempt resource level shall be applicable for an individual and the two person level for an individual who is living together with his or her spouse, parent, or other legally responsible family member (whether or not the member is a cash or medical recipient or eligible for Pickle status as well).
All aged and disabled OASDI recipient who apply for or are interprogram transferred to Medically Needy shall be screened for eligibility under the Pickle Amendment. If all screening criteria are met, an income determination is to be completed. The ES-3104.6, Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups form, is to be used for this purpose. Verification must be provided by the individual of his or her SSI termination date, previous concurrent OASDI/SSI status,and current OASDI benefit amount.
An income determination is not required for those SSI recipients who lose their SSI eligibility at the time of an OASDI cost-of-living increase and are interprogram transferred to Medically Needy. The Pickle code for persons with excess income as noted below shall be reflected for those who lose their SSI eligibility at any time other than a COLA increase.
To determine total countable income, the person's countable OASDI amount must first be computed by subtracting the COLA amount to be disregarded from the current gross OASDI monthly benefit.
The COLA disregard is determined by using the ratio from the COLA Ratio Table at the bottom of the worksheet which corresponds to the time period in which the individual received his or her last SSI payment and multiplying that ratio by the OASDI benefit. The disregard is to be rounded down to the nearest penny. A countable OASDI amount shall also be computed for the individual's spouse, parent, or other legally responsible family member, if living together (excluding HCBS arrangements), whether or not that person also qualifies for Pickle eligibility. Both amounts shall be computed separately and then combined.
The countable OASDI amount is then added to all other gross income. For individuals who live with a legally responsible family member (whether that person qualifies for Pickle eligibility or not), all other income of the member must also be considered in the determination. The total countable income obtained shall be compared to the current appropriate SSI benefit level.
For individuals living alone or living in someone else's household, the total countable income shall be compared to the one person SSI benefit level or prorated one person benefit level respectively. For individuals living with a spouse who has no income, the one person SSI benefit level (or prorated level if in someone else's household) shall be used. For individuals living with a spouse who has income or also qualifies for Pickle eligibility, the two person SSI benefit level (or prorated level if in someone else's household) shall be used. In all other situations, a one person SSI benefit level shall be used.
If the total countable income is less than the appropriate SSI benefit level, there is eligibility for Pickle status. Medicaid eligibility would be provided with no spenddown requirement beginning with the first eligibility base period (including prior medical, if requested).
If the total countable income is greater than the appropriate SSI benefit level, there is no eligibility for Pickle status currently. Such individuals may qualify at the time of a future OASDI COLA increase.
Persons eligible for Pickle status shall be reviewed on an annual basis in accordance with 9372. If there has been no change in circumstances during the year such as a change in entitlement status, increase in other income, or change in living arrangement, Pickle eligibility will continue. Persons who do not qualify for Pickle eligibility because of excess income and who retain eligibility for medical must be reviewed at the time of each COLA increase.
Although persons qualifying for Pickle status will be eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus, the income and resources of a person receiving medical under the Pickle Amendment would be considered in determining the cash and medical eligibility of his or her non-Pickle eligible spouse and minor child.
Based on a provision contained within the Consolidated Budget Reconciliation Act of 1985 (COBRA) persons who lose their SSI eligibility (including eligibility under section 1619 per 2634) because of an increase to their Social Security disabled widow's or widower's benefits may qualify for medical assistance without a spenddown if they meet all of the following criteria:
This provision is not applicable to those who (1) receive SSI or cash assistance or (2) reside in a nursing facility or state institution. Qualifying individuals must meet all Medically Needy nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections.
Application for eligibility under this provision must be made prior to July 1, 1988. Each state received information from SSA identifying all persons residing in that state who potentially qualified under this provision. Thus, persons applying for eligibility under this provision in Kansas must present evidence of having been notified of their potential eligibility or of having qualified for assistance under this provision. Persons who qualified prior to July 1, 1988, in another state and who move to Kansas can be determined eligible here if continued coverage under this provision is requested.
Verification of their eligibility status in the other states is required. Persons who were notified of their potential eligibility in another state but did not apply and who later move to Kansas must apply for benefits under this provision prior to July 1, 1988.
If the above evidence is presented, an income determination shall be completed. The amount of the person's Social Security benefit prior to the reduction factor increase and any subsequent COLAs must be verified. This amount shall be added together with all other current nonexempt gross income. The Medically Needy income disregards as described in 7240 shall be applied to the total income. The countable income obtained shall then be compared to the current SSI benefit level for 1 person (either the full amount or the prorated amount if living in someone else's household).
The ES-3104.6 shall be used for determining countable income by using Lines 3-9. The person's Social Security benefit prior to the reduction factor increase would be inserted on Line 3.
If the total countable income is less than the appropriate SSI benefit level, the person qualified for medical eligibility without a spenddown. Such eligibility shall begin with the first eligibility base period (including prior medical, if requested).
If the total countable income is greater than the appropriate SSI benefit level, the person does not qualify, and a regular medical determination shall be developed.
Persons eligible under this provision shall be reviewed on an annual basis in accordance with 9372. If there has been no change in circumstance such as an increase in other income or loss of disabled widow or widower status, such eligibility shall continue. Although qualifying persons are eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus, the income and resources of a person receiving medical under this provision would be considered in determining the cash and medical eligibility of any dependent children.
Based on the Employment Opportunities for Disabled Americans Act of 1986, persons who qualify for Social Security benefits as "adult disabled children" may be eligible for medical assistance without a spenddown if the following criteria are met:
This provision is not applicable to those who (1) currently receive SSI or cash assistance or (2) reside in a nursing facility or state institution. Qualifying individuals must meet all Medically Needy nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections.
NOTE: Adult Disabled Child benefits can be identified by a Social Security Claim Number which ends with a "C".
For applicants who receive SSA benefits under the "adult disabled child" category, a determination of whether or not the individual had previously been an SSI client and, if so, whether or not the individual lost SSI eligibility on or after July 1, 1987 due to his or her adult disabled child benefit must be made. Verification of these qualifications along with the person's adult disabled child benefit level prior to SSI termination would be required. If the above conditions are met, a determination of the individual's financial and nonfinancial eligibility would then be completed.
All clients who lose SSI eligibility at the time he or she becomes eligible for Adult Disabled Child benefits are eligible for medical assistance without a spenddown. They would remain eligible for automatic medical as long as they would be otherwise eligible for SSI if not for the adult disabled child benefits.
To determine income eligibility for applicants as well as continuing eligibility for ongoing clients, the amount, if any, of the person's adult disabled child benefit in the month prior to the month of the increase which resulted in ineligibility for SSI must be verified. If the person became newly eligible for an adult disabled child benefit, this amount would be "0." This figure shall then be inserted on the ES-3104.6, Determination Worksheet for Pickle Eligibiles and Other Protected Medical Groups in Line 3 to determine total countable income. If the total countable income is less than the appropriate SSI benefit level, the person continues to qualify for medical eligibility without a spenddown. If the income is greater than the SSI level, the person would not qualify and a regular medical determination would be required. The income determination would not be required at the time an ongoing client loses SSI eligibility unless some other change in income occurred at the same time. This determination should occur on at least an annual basis as indicated below.
Persons eligible under this provision shall be reviewed on an annual basis in accordance with 9372. If there has been no change in circumstance such as an increase in other income or loss of disabled child status, such eligibility shall continue. Although qualifying persons are eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus the income and resources of a person receiving medical under this provision would be considered in determining the cash and medical eligibility of any spouse or children.
Persons who lose their SSI eligibility (including eligibility under section 1619 per 2634) because they begin receiving early or disabled widow or widower Social Security benefits may qualify for medical assistance without a spenddown if they meet the following criteria:
This provision is not applicable to those who (1) currently receive SSI or cash assistance or (2) reside in a nursing facility or state institution. Qualifying individuals must meet all Medically Needy nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections.
For applicants who receive early or disabled widow or widower's benefits and meet the age and Medicare criteria described above, a determination of whether or not the individual has previously been an SSI client and, if so, whether the individual lost SSI eligibility due to the receipt of such benefits must be made. Verification of these qualifications along with the current widow/widower benefit amount would be required. A determination of the individual's financial and nonfinancial eligibility would then be completed.
Ongoing SSI clients who lose SSI eligibility due to becoming eligible for early or disabled widow/widower benefits shall be considered as having met items 2 and 3 in the above criteria (including financial and nonfinancial requirements). A determination of the age and Medicare eligibility criteria would then be made. Verification of the reason for SSI termination will be required. Qualifying individuals would remain eligible for medical assistance without a spenddown as long as they continue to meet the above provisions.
To determine income eligibility, the ES-3104.6 shall be used. All of the individual's nonexempt income except the widow/widower benefit would be inserted on Lines 4-6 of the worksheet and the resulting total countable income determined. If the total countable income is less than the appropriate SSI benefit level, the person would qualify for medical assistance without a spenddown. If the income is greater than the SSI benefit level, the person would not qualify, and a regular medical determination would be required. An income determination would not be required at the time an ongoing client loses SSI eligibility as indicated above unless some other change in income occurred at the same time.
This determination should occur on at least an annual basis as indicated below.
Eligibility under this provision shall end in the month in which the individual turns 65 or becomes eligible for Medicare Part A, whichever occurs first. An annual review shall be conducted in accordance with 9372. If there has been no change in circumstance such as an increase in other income, such eligibility shall continue until the age limit or Medicare eligibility is reached.
Although qualifying persons are eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus, the income and resources of a person receiving medical under this provision would be considered in determining the medical eligibility of any dependent children.