Adult Medicaid Manual MA-1000 SSI MEDICAID AUTOMATED PROCESS

III. AUTOMATION OVERVIEW

A. State Data Exchange (SDX)

SSA transmits information regarding SSI recipients and applicants to the State using the SDX. The State uses information on the SDX to create a Medicaid record in EIS for each SSI recipient. The SDX controls Medicaid eligibility for SSI recipients. Except for the situations identified later in this section, only the SDX can update information in EIS for an SSI recipient. This is true even when the county dss has verified information that is inconsistent with the data on the SDX.

Social Security sends SDX updates to the State several times a week. The updates are compiled and processed once a week for Medicaid issuance for SSI recipients. Generally the updates are run on Friday night.

The on-line SDX is updated daily as updates are received from Social Security. Therefore, it is possible for an individual to be on the SDX before he is in EIS.

B. EIS Uses Information on the SDX To:

1. Create an SSI MAABD case (or modify an existing Medicaid case in EIS to SSI Medicaid).

2. Update case and individual data in EIS for ongoing SSI Medicaid recipients.

3. Issue automated approval, denial, termination and redetermination notices.

4. Issue Medicaid cards for SSI recipients.

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(III.B.)

5. Terminate Medicaid when an SSI recipient dies or moves out of state.

6. Change to SSI status when SSI stops.

C. SSI Medicaid Recipients In EIS

An SSI Medicaid case is in EIS just as a regular Medicaid case is in EIS, with case and individual data and history.

1. SSI Status

a. SSI Medicaid Recipients - The SSI status is "Y" for SSI recipients. EIS/SDX controls most of the data on these cases. See III.D., below or refer to the EIS Manual, Section 4200, Part 5.

b. SSI Medicaid Recipients In Ex Parte Review Status - The SSI status is "N" and the “Certification Thru Date" is 12/31/9999. Do not make changes to the case in EIS until the ex parte review is completed.

c. Non-SSI Medicaid Recipients - The SSI status is "N" for non-SSI recipients. The county dss controls all data on these cases.

2. Aid Program/Category

The aid program/category is always MAA, MAB, or MAD except for the following situations:

a. SSI recipients who also receive Special Assistance are SAA or SAD.

b. SSI children in foster care are HSF.

c. SSI recipients in a single person Transitional Medicaid case (payment type 5) remain AAF.

3. Classification

SSI recipients are always Categorically Needy. The classification code in EIS is:

a. “C” for SSI recipients who do not have Medicare, or

b. “Q” for SSI recipients who are entitled to Medicare.

4. Individual Eligibility History (IE)

a. The IE segment indicates the individual is an SSI Medicaid recipient beginning with the first month of SSI.

b. The certification thru date is always 12/31/9999.

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(III.C.4)

5. ID Cards

All SSI recipients receive a gray Medicaid card. For MAABD cases in a private living arrangement (pla), the district number is “SDX” on the EIS case and ID card to indicate the individual is an SSI Medicaid recipient. SAA, SAD, AAF, HSF, and LTC cases retain the district number assigned by the county dss.

D. Creating/Updating an SSI Medicaid Case in EIS

For all SSI recipients, EIS uses information on the SDX to create and update SSI Medicaid cases in EIS. The county dss cannot change data in EIS for SSI recipients, with certain exceptions. (Refer to EIS 4200, Part 5, for a chart which shows all allowable county changes.) This is true even when the county dss has verified information that is inconsistent with data on the SDX.

1. SSI, MAA, MAB, or MAD recipients:

The county dss can update the following fields in EIS:

a. Change the living arrangement from private living arrangement (PLA) to long term care (LTC) and from LTC to PLA.

b. Transfer the case to HSF.

c. Approve a reapplication for money payment (SAA, SAD, AAF).

d. Enter CAP date.

Refer to EIS 4200 Part 5, for instructions.

2. SSI Recipients in Special Assistance (SAA or SAD) or in Single Person AAF case (payment type 5)

The county dss can update some fields in EIS to control the issuance of the check and ensure automatic Medicaid issuance for SSI recipients in these categories. The county dss can also transfer the case to MAABD. Refer to EIS 4200 Part 5, for instructions.

3. SSI Recipients in HSF

The county dss can update some fields in EIS to indicate custody/placement responsibility. The county dss can also transfer the case to MAABD. Refer to EIS 4200 Part 5, for instructions.

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(III.)

E. Reporting Changes

1. SSI recipients must report to Social Security all changes that affect SSI (including change of address). When Social Security updates the SDX, the change is reflected in EIS. If an SSI recipient reports a change to the dss, instruct him to report the change to the local Social Security Office. Explain that his Medicaid record can only be changed by SSA. Give him the address and phone number of the district office. DO NOT REPORT ROUTINE CHANGES TO SOCIAL SECURITY. IT IS THE RECIPIENT'S RESPONSIBILITY.

2. SSI recipients in LTC, SAD, SAA, HSF, or AAF payment type 5 (situations where the county dss has the capability to update some fields in EIS) must also report changes that affect Medicaid to the county dss. When changes are reported, treat this as change in situation. Update the allowable fields in EIS.

3. When an SSI recipient reports health insurance information to the dss, complete a DMA-2041, Third Party Health and Accident Resources Information. Enter this information in EIS. If the recipient does not have enough information to enable you to complete the DMA-2041, instruct him to obtain the additional information and advise him to contact you with the information as soon as possible.

4. When an SSI recipient also receives Food Stamps or other DSS services, notify the other program immediately of any changes the recipient reports to you.

5. When the dss learns of a change in an SSI Medicaid recipient's situation that might affect his eligibility for SSI and Medicaid, and the client does not/cannot report the change to SSA, use the DMA-5049, Referral to the Local Social Security Office, to report information to the local SSA office. Use this referral only when SSA is not aware of the change in situation. Examples of when to use this referral:

a. DSS learns SSI recipient dies

b. SSI recipient enters a public institution, nursing facility, or rest home

c. DSS learns information that affects SSI payment

d. DSS suspects fraud

6. The county dss may discover information on the SDX is incorrect. The information may not affect SSI eligibility, but it may cause a problem with Medicaid claims, buy-in or some other factor that affects Medicaid eligibility. Use the DMA-5049, Referral to the Local Social Security Office, to report this information immediately to SSA. Use "Other" to specify the problem. SSA must correct its record in order for the SDX to update EIS. For example, the dss verifies an individual is age 64 or less, but the SDX indicates he is 65. Medicaid claims will be denied until the problem is corrected.

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(III.E.)

7. In the unusual situation that SSA does not react to changes reported by the client or dss and it is causing a hardship for a recipient or provider, contact DMA, Medicaid Eligibility Unit. A policy consultant will work with you on a case by case basis.

F. Buy-In

SSI recipients who are eligible for Medicare are automatically accreted for buy-in by SSA. Buy-in is effective the first month of Medicaid eligibility. SSI recipients remain on buy-in until Medicaid is terminated. See MA-2410, Medicare Enrollment and Buy-In.