Adult Medicaid Manual MA-1000 SSI MEDICAID AUTOMATED PROCESS

V. LIMITATIONS TO MEDICAID ELIGIBILITY FOR SSI RECIPIENTS

A. Refusal to Provide Third Party Resource (TPR) Information

Providing TPR is not a requirement for SSI, but it is a requirement for all Medicaid programs. When an SSI applicant refuses to provide TPR to SSA, he is advised by SSA that he is not eligible for Medicaid. No action is required by the dss until the recipient contacts the dss.

1. Identification

a. Individuals who refuse to provide TPR information are indicated on the SDX by an “R” for the Medicaid Eligibility Code and an "R" for the Third Party Insurance indicator.

b. This information is also reported on either the SSI Approval -Medicaid Denial (TPR Refusal) Report (see V.A.2., below) or the TPR Refusal - Medicaid Terminated Report (see V.A.3., below). Refer to EIS 4200 for further information on these reports.

NOTE: Active SAA, SAD, and HSF cases are not terminated. TPR refusal is reported on the TPR REFUSAL-SSI INDIVIDUAL RECEIVING SAA/SAD/HSF Report. This report is for informational purposes.

REVISED 11/01/11 – CHANGE NO. 17-11

(V.A.)

2. SSI Approval/Medicaid Denial (TPR Refusal) Report

a. For an SSI approval/Medicaid denial, EIS does not create a Medicaid case or generate a Medicaid card.

b. EIS sends an automated Medicaid denial notice. See DMA-5103D, SSI Denial Notice.

3. SSI Approval/Medicaid Terminated Report (except SAA, SAD, or HSF)

a. When the individual is in a single person case, the case is terminated.

b. When the individual is in a multiple person case, the individual is deleted from the case.

c. EIS sends an automated termination notice. See DMA-5103T, SSI Termination Notice.

4. Appeal Rights

a. The individual is advised in the denial or termination notice that:

(1) He may request an appeal to his county dss within 60 days from the date of the notice if he does not agree with the denial or termination, or

(2) He can become eligible for Medicaid by providing TPR information to the local county dss.

b. If the individual contacts the county dss and requests an appeal, follow procedures for local hearings in MA-2420, Notice and Hearings Process, for local hearings. Prepare a summary which states: “Social Security has advised the State that you refused to provide medical insurance information.”

c. The Medicaid denial or termination can be reversed only when the individual provides his insurance information. This can be done at the appeal or any time the information is provided.

d. When the recipient provides the necessary medical insurance information:

(1) Use the DMA-5049, Referral to Local Social Security Office, to inform the local SSA office that the recipient has provided the necessary medical insurance information. Request that SSA delete the “R” code from the recipient's record. When the SSA record is updated, this information will be transmitted to the State via the SDX.

REVISED 11/01/11 – CHANGE NO. 17-11

(V.A.4.d.)

(2) When the SSI Medicaid case is created, complete the DMA-2041, Third Party Health and Accident Resources Information, and enter the insurance information in EIS.

The individual will not receive SSI Medicaid until the corrected information is transmitted to EIS via the SDX. EIS will then automatically create an SSI Medicaid case and issue a notice and card effective the month SSI is effective.

B. Trusts

Certain trusts are not a countable resource in determining SSI eligibility. They may be a countable asset for Medicaid, and therefore affect Medicaid eligibility. When the SDX indicates the individual has a certain trust, EIS will generate a report to DMA.

The DMA Medicaid Eligibility Unit will send notification to the county along with a copy of the EIS report. The county will evaluate the report for effect on eligibility.