A. MA-1000, SSI Medicaid-Automated Process, is revised to state if the individual's SSI disability denial or termination is in appeal status, continue to cover the individual under Medicaid for the Disabled as long as he meets other Medicaid eligibility criteria and until a final decision is rendered by the Appeals Council with no right to further administrative appeal.
B. MA-2352, Terminations and Deletions, is revised to include under exparte reviews, continuation of MAD when a MAD’s recipient’s Social Security or SSI disability is terminated or denied due to not being disabled and he has requested an appeal through Social Security.
C. MA-2420, Notice and Hearings Process, is revised to include the recipient has the right to continued benefits if requested during the timely notice period. The benefits can continue until the state hearing decision or the social security disability appeal decision is rendered on RSDI/SSI denials or terminations based on disability.
D. MA-2525, Disability, is revised to include active MAD recipients who may have Medicaid continued when Social Security or SSI has been denied or terminated and the recipient is appealing the decision.
DATE: JUNE 24, 2002
Manual: Aged, Blind and Disabled Medicaid
Change No. 03-03
To: County Directors of Social Services
Effective: July 1, 2002
We are revising policy to continue Medicaid for disabled MAD recipients, who appeal their Social Security/SSI termination of disability. The MAD recipient continues to be considered disabled for Medicaid purposes while pursing appeal of the Social Security or SSI termination or until a final decision is rendered by the Appeals Council with no right to further administrative appeal. This follows existing policy for continuation of Medicaid for an active MAD recipient with Social Security/SSI Disability denial, which is under appeal.
When the active MAD recipient has requested an appeal of his disability denial or termination through Social Security, the recipient’s Medicaid can continue if he meets all other Medicaid non-disability requirements. If ultimately determined not disabled, there is no overpayment for Medicaid benefits. Counties can advise recipients to contact their local Social Security Office to appeal the disability denial or termination from Social Security.
Policy is amended to clarify when an active MAD recipient appeals a Medicaid denial or termination based on an adoption of an SSA denial of disability, the local or first appeal is a State level hearing. If appealing the termination, he has the right to continued benefits. Medicaid benefits may continue through the State level hearing, as that is the 1st hearing in the appeal process.
If determined not disabled by a State Hearing Officer, there is an overpayment for the continued Medicaid benefits the recipient received. However, if the recipient is also appealing through Social Security, there is no overpayment during that time frame.
If the individual’s SSI is terminated for no longer being disabled, the county completes an exparte review. The four month exparte period begins with the month of the SSI termination. Immediately begin the exparte review. The caseworker can advise the recipient to appeal the SSA/SSI disability termination or denial through Social Security. Information on the SDX is no longer current as the SSI case is no longer active, so income, resources and other information subject to change must be verified. The caseworker at this point may not know if the person will appeal his SSI disability termination.
Begin evaluation for eligibility for other coverage groups. Inquire whether the individual is pregnant or if he or she has minor children in the home. However, do not require the verification that will be needed for such coverage groups until the individual fails to timely appeal the SSI termination.
If the person does appeal the SSI disability termination within 60 days, the exparte review is complete. Flag the case and continue to track the SSI appeal, according to MA-2525. Determine if the recipient is receiving Medicare Part B. Contact your local Social Security Office to determine if the person in appeal status will continue to receive the Medicare Part B. If necessary, change the classification code from Q or B to N or M when the Medicaid is continued and the client loses his/her Medicare benefit.
If the person does not appeal the SSI termination by the 60th day he is no longer considered disabled and is ineligible for MAD. Complete an evaluation of eligibility under other Medicaid coverage groups. This should have already begun.
VII. G. 5. is updated to follow current policy in MA-2375, Procedures for Child Support Enforcement.
The reference to penalty checks is deleted in VI.A.
The DMA-5009 is added to MA-2525 as Figure 8. The name of the form is revised from “Social History Summary for the Disabled and Selected AFDC Cases” to “Social History Summary for the Disabled”. Please remove this form from MA-5000.
Apply this change to any pending applications, redeterminations, exparte reviews and appeals in process as of July 1, 2002.
Insert: MA-1000, pages 1-4 and 9-17.
Online Manual: Revised items II.E. and VII. A-E.
Insert: MA-2352, pages 3 and 4.
Online Manual: Revised item II.D.
Insert: MA-2420, pages 21-29.
Online Manual: Revised items VI.A.9, VI.B. through VI. F.
Insert: MA-2525, pages 3 - 6 and 15 - 25, and Figure 8.
Online Manual: Revised items II.G. and VIII.A.through XIII..
If you have any questions, please contact your Medicaid Program Representative.
[This material was researched and written by Denise Rogers, Policy Consultant, Medicaid Eligibility Unit.]
MA-2525, Figure 8
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.