Adult Medicaid Manual MA-1000 SSI MEDICAID AUTOMATED PROCESS

VII. SSI TERMINATIONS

When SSI terminates, evaluate ongoing eligibility for Medicaid in all aid program/categories. The individual remains authorized after SSI is terminated while the evaluation is completed.

When the SSI termination processes in EIS, the termination appears on the SSI TERMINATION REPORT. The SSI indicator changes to "N." The case remains open with a Medicaid through date of 12/31/9999. Within 5 workdays the county dss must initiate an ex parte review to determine whether the recipient qualifies for Medicaid under any other coverage group, including Family and Children's Medicaid which includes pregnant woman coverage, family planning waiver, North Carolina Health Choice for Children, or Work First Family Assistance. For SSI terminations for disability reasons, see D. for ex parte procedures.

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(VII.)

A. Automated Recipient Notice

When the SDX indicates a recipient is being terminated from SSI, EIS generates an automated notice to the recipient. See DMA-5100, Notice of Medicaid Redetermination.

The notice advises the recipient:

1. To contact the local SSA if he wants to appeal the SSI termination.

2. The county dss must determine whether he may continue to be eligible for Medicaid as a non-SSI recipient.

3. The county dss will contact him if further information is needed.

When the determination is completed, a timely notice will be sent to inform the recipient of the Medicaid decision.

B. Time Frames for Completing the Evaluation of Ongoing Medicaid Eligibility (Ex Parte Review)

1. Initiate the evaluation of ongoing eligibility within 5 workdays of the date the termination appears on the SSI TERMINATION REPORT. This is essential to ensure enough time to evaluate for ongoing eligibility.

Use the Adult Medicaid Applications or the DMA-5007, MAABD Redetermination Document, as the base document for the evaluation for ongoing eligibility. The SSI recipient's signature is not required for the evaluation, nor can the recipient be required to come into the agency.

Within 4 months of the month the SSI terminated, the county dss must complete the evaluation of ongoing eligibility and notify the recipient about his ongoing eligibility for Medicaid. The four month period begins the month the case appears on the SSI TERMINATION REPORT.

For example, the case appears on the SSI TERMINATION REPORT in July. July, August, September and October are continuation months. Complete the evaluation of eligibility and send the timely notice to make the decision effective no later than October 31.

2. Federal financial participation for up to four months is available for Medicaid during the evaluation. Counties may be liable for charge backs of Medicaid expenditures for ineligible cases if the Medicaid must be extended longer than 4 months to complete an evaluation and/or send timely notice of termination.

3. Recipient Lives In A County Different From That On The SSI TERMINATION REPORT.

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(VII.B.)

If the recipient lives in another county, the county dss in which the SSI TERMINATION REPORT appears must contact the dss in the county of residence immediately and tell them of the SSI termination. Within 5 workdays the first county must send a copy of the SSI TERMINATION REPORT to the county of residence who must complete the evaluation. Once completed, the first county must be notified so they can key in the results of the evaluation and, if eligibility continues, transfer the case to the county of residence. Cooperation between the two counties is essential to ensure that the evaluation for ongoing coverage is completed timely and there is no break in coverage for the recipient.

C. Medicaid Evaluation for Ongoing Eligibility - Ex Parte Review Procedures

The term “ex parte review” means to review information available to the agency to make a determination of eligibility, without requiring the recipient to come into the agency or make a separate application. The county must explore and exhaust all possible avenues of eligibility in all Medicaid coverage groups. If information is not available to make a determination of eligibility, the county must provide the recipient reasonable opportunity to provide the necessary information. Do not require citizenship/identity documentation during an ex parte review. See MA-2506, US Citizenship Requirements.

1. What Information Must be Reviewed

Review only those eligibility factors that are subject to change, such as income or resources. Do not reverify factors that are not subject to change, such as date of birth or citizenship.

2. Where to Look For Possible Sources of Information

Review all possible sources of information available to the agency, including information verified by other programs. Medicaid eligibility is determined according to the rules of the appropriate Medicaid coverage group. However, the county must accept as accurate verifications from other programs, including:

a. Information available through automated queries, such as SDX, BENDEX, TPQY, SOLQ, ESC, ACTS and FSIS. (Refer to MA-2430, Automated Inquiry and Match Procedures, and EIS 1103 for instructions on using the SDX, BENDEX, SOLQ and other online inquiries.)

b. Information collected in the determination of eligibility for other programs, such as Food Stamps, Work First, child care assistance, IV-D child support services and adult or children's services, if the information can be released by the other programs within its rules for confidentiality. For example, child protective services records may not be available.

c. Information that is current. "Current" means that the information was obtained and verified by the other program within the time frames for redeterminations of eligibility for the Medicaid coverage group being considered, unless there is reason to believe it is inaccurate.

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(VII.C.2.c)

Current also means that the case is active. Information obtained from a closed or terminated program is not considered current even if verified during the appropriate time frames. A case in suspense is considered active.

For SSI terminations, information on the SDX is no longer current as the SSI case is no longer active. Income, resources and other information subject to change must be verified. The former SSI recipient is exempt from citizenship/identity requirements. Use citizenship/identity code 50, permanently exempt.

For example, if the recipient is being evaluated for MAF Medically Needy and the certification period is 6 months, the information must have been verified within the last 6 months. If the recipient is being evaluated for MIC and the certification period is 12 months, the information must have been verified within the last 12 months. In both situations the case in the other program must be currently active.

3. Whose Information to Review

a. Check all possible sources of information in the SSI recipient's name.

b. If the names of immediate family members (spouse, parents and stepparents, adult or minor children, and siblings) who live with the recipient are known, check all records in their names. See DMA-5138, Ex Parte Review Checklist (Non-MIC/NCHC Re-Enrollments), for a suggested checklist to document family members.

D. Continuation of MAD When SSI Disability Termination is in Appeal Status - Ex Parte Procedures

When the SSI disability benefit of an active MAD recipient is terminated for no longer being disabled, he or she may continue to be considered disabled while pursuing appeal of the SSI termination. The recipient has only 65 days to request an appeal with Social Security/SSI unless SSA accepts a late appeal for good cause.

1. The case will appear on the SSI Termination Report. Begin the ex parte review process in five work days.

a. If the recipient appeals the SSI termination within 65 days or SSA accepts the appeal with good cause and the recipient meets other non-disability criteria for MAD, the ex parte review is complete.

Flag the case and continue to track the SSI appeal according to MA-2525, Disability. Determine if the recipient is receiving Medicare Part B. Contact the Social Security Administration to determine if the recipient will continue receiving Medicare Part B while the SSI termination is being appealed. If necessary, change the classification code from Q or B to N or M when the Medicaid is continued but the recipient no longer receives his Medicare benefit.

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(VII.D.1.)

b. If the recipient does not appeal the SSI termination timely, the recipient is no longer considered disabled and is ineligible for MAD when:

(1) He ceases to pursue the SSI appeal up to the appeals council,

(2) SSA doesn’t accept the appeal for a good cause reason.

2. Begin the process by evaluating eligibility in all coverage groups. Use all agency verifications to determine eligibility before contacting the a/r. Use the DMA-5180, SSI Check Terminated: Information Needed to Determine Medicaid Eligibility, to contact the a/r. If additional information is needed, use the DMA-5097, Request for Information.

a. If the recipient remains eligible in another category, immediately transfer the case to that aid program category.

b. The county must complete the ex-parte review process in four months. The four months begin the month the case appears on the SSI termination report.

c. If the recipient is not eligible in another category, terminate the case after timely notice.

3. If the recipient appeals the county’s decision to terminate the case and recipient alleges he is still disabled, request a state hearing. The State Hearing Officer determines if the recipient meets one of the conditions in a., b., or c.

a. Has a disabling condition different from, or in addition to the conditions considered in the original SSA disability decision, or

b. Alleges more than 12 months after the most recent SSA termination for not being disabled that his condition has changed or deteriorated and his period of disability meets the 12 month durational requirement, and he has not reapplied at SSA based on those new allegations, or

c. Alleges less than 12 months after the most recent SSA termination for not being disabled, that his condition has changed or deteriorated, and his period of disability meets the 12 month durational requirement, and

(1) He has applied to SSA for reconsideration or reopening and SSA refuses to consider the changes, and /or

(2) He does not meet other SSI eligibility requirements e.g., reserve, but may meet the state’s Medicaid eligibility requirements for MAD.

4. If the State Hearing Officer determines that a., b., or c. applies, then the State Hearing Officer will determine if the recipient meets the disability requirements. If the Hearing Officer determines the recipient is still disabled, MAD is continued or reinstated.

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(VII.D.4.)

A continuing SSA appeal is not a requirement if the hearing officer determines that 3. a., b., or c. applies and that the a/r is disabled.

E. Evaluate All Coverage Groups

Evaluate the recipient's eligibility in all coverage groups. This may involve contacting the recipient to obtain additional information, ONLY if necessary information is unavailable to the agency from another source or is not current. See F.

If the recipient is eligible in more than one coverage group, the recipient has a right to choose the coverage group. Explain the advantages of each coverage group and document the recipient's choice.

1. MAD - Refer to D. for continuation of MAD when SSI disability termination is in appeal status.

If the recipient’s SSI was terminated for a non-disability related reason, such as income, evaluate for MAD. If the recipient remains eligible, as MAD, continue MAD. At the next regular eligibility redetermination, submit forms to DDS to establish a regular “Diary/Re-Exam Date” for ongoing reviews of disability.

2. Children Terminated from SSI With Protected Status - Refer to MA-2525, Disability, for instructions for evaluating children with protected status.

3. MAA - If the individual is aged 65 or older, evaluate for MAA.

4. MAB - If the individual has been determined to be blind by Social Security, evaluate for MAB.

5. MAF - Evaluate for MAF-C. If it appears the recipient is eligible for MAF-C, then, advise a/r to apply for Work First. However, approve him for MAF-C if eligible. If the SSI recipient’s family is authorized for Work First, the former SSI recipient must be added to the Work First assistance unit.

6. Other Family and Children's Medicaid

a. Evaluate the recipient's eligibility in all Family & Children's categories, including MAF, MIC, NCHC, HSF, MPW, Breast and Cervical Cancer Medicaid and Family Planning Waiver.

b. If it is known to the agency that the recipient is pregnant, contact the recipient to request verification of pregnancy to evaluate for MPW. If there is no information to indicate pregnancy, continue to evaluate in other coverage groups. It may be necessary to contact the recipient to inquire whether she is pregnant if there is no other basis for eligibility. See instructions in F.

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(VII.E.)

c. Medicaid Family Planning Waiver (FPW) – If the recipient is a female age 19 through 55 or a male age 19 through 60, with an income at or below 185% of the federal poverty level, and is not eligible for any other coverage group, evaluate for FPW.

7. North Carolina Health Choice for Children - If the recipient is up to age 19 and is not eligible for Medicaid in any other coverage group, evaluate for North Carolina Health Choice for Children.

F. When and How To Request Information From The Recipient

Information must be requested from the recipient only when it is necessary to determine ongoing eligibility AND the information is not already available to the agency or is not current as described in C.2.

1. Necessary information may be requested by telephone or in writing. If a telephone request is made, advise the recipient what information is needed and that he may request additional time or assistance in obtaining necessary information. Document the record to show the date of the telephone contact, the specific information requested and that the recipient was offered assistance. If the request is in writing, use the DMA-5097, Request for Information.

2. Allow the recipient at least 12 calendar days from the date of the request to provide the information. For example, if a DMA-5097, Request for Information is mailed on January 7 to request current wage information, the deadline for providing the information is January 19.

3. If the recipient does not provide the requested information by the deadline, send timely notice proposing termination for failure to provide the necessary information.

4. Letter to Recipient Prior to Termination

There may be situations in which there is little or no information in the agency regarding an SSI recipient. If you complete the evaluation above and the only potential coverage groups available are in Family & Children's Medicaid, eligibility cannot be established without determining if the recipient is pregnant or has minor children living in the home.

For example, a 34 year old SSI recipient is terminated because she is no longer disabled. She does not receive any other services and is not known to the agency. She could potentially be eligible for MPW if she is pregnant or as an MAF caretaker if she has minor children living with her. If she appeals the SSI termination timely, she can continue to receive MAD.

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(VII.F.4.)

a. Send a DMA-5180, SSI Check Terminated: Information Needed to Determine Medicaid Eligibility, to the recipient advising that Medicaid eligibility is being evaluated and additional information is needed. This letter asks if the recipient is pregnant or has minor children living in the home. The letter also explains the Medicaid Family Planning Waiver and asks the recipient if he wishes to apply.

b. Allow the recipient at least 12 calendar days to return the letter or contact the agency. If the recipient contacts the agency by the deadline, the recipient may request additional time to obtain necessary information such as pregnancy verification.

If the recipient answers yes to either question but provides no other information, contact the recipient to determine if he needs assistance obtaining documentation. Document all efforts to assist the recipient.

c. If there is no response to the letter by the deadline date, either by phone or in writing or in person, and the recipient is not eligible in any other category, send a timely notice to propose termination.

G. Results of Evaluation for Ongoing Eligibility

1. When all necessary information has been obtained and/or requested, determine whether the recipient is eligible for Medicaid under any aid program/category. One of several eligibility outcomes is possible:

a. Recipient is eligible for full Medicaid (MAABD or Family & Children's Medicaid) without a deductible; or

b. Recipient will be eligible for full Medicaid (MAABD or Family & Children's Medicaid) if he meets a deductible (Medically Needy), or recipient is eligible as MQB, Q, B, or E, Family Planning Waiver or Breast and Cervical Cancer Medicaid; or

c. Recipient is eligible for North Carolina Health Choice for Children; or

d. Recipient is ineligible for Work First; or

e. Recipient is ineligible for any Medicaid coverage; or

f. Recipient did not provide necessary information and coverage must be terminated after timely notice.

2. It is also possible that an additional application may be necessary if the recipient requests assistance for other family members, such as a spouse or children, during the review. Treat the request for additional coverage as a separate application.

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(VII.G.)

3. If eligibility is established in any coverage group, the certification period begins with the current processing month in EIS.

Example: Review completed January 27. The current EIS processing month is March. The new certification period begins March 1.

4. If the recipient is eligible as MQB (Q, B or E) only, transfer the case to MQB.

5. Deductible Cases

a. If the recipient is eligible for Medicaid but must meet a deductible, contact the recipient regarding his predicted or outstanding medical expenses to determine if he can meet the deductible.

He can if:

(1) His deductible amount is $300 or less, or

(2) His predicted expenses or old bills are within $300 of meeting the deductible.

b. If it is determined that the recipient can meet his MAABD deductible:

(1) Certify and put the case in deductible status.

(2) Follow deductible policy in MA-2360, Medicaid Deductible, to apply medical expenses to the deductible.

(3) Indicate the deductible amount on the automated notice.

c. If it is determined that the recipient can meet an MAF deductible:

(1) Terminate the MAABD case.

(2) Enter an administrative DSS-8124 to open an MAF case.

(3) Pend the application to meet the deductible. (MAF cases cannot be approved in EIS in deductible status.)

d. If it is determined that the recipient's deductible is greater than $300 or the predicted medical expenses are not within $300 of meeting the deductible, send timely notice to propose termination.

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(VII.G.)

6. MIC or MAF Cases

a. Caretakers for SSI children must cooperate with IV-D to establish medical support agreements when the following applies:

(1) The caretaker is applying for or receiving Medicaid for herself in any aid/program category except MPW. Refer to MA-2375, Procedures for Child Support Enforcement.

OR

(2) The child meets the criteria listed in MA-2375, Procedures for Child Support Enforcement.

b. If the recipient is eligible as MIC or MAF, terminate the MAABD case. Enter an administrative DSS-8124 to open an MIC or MAF case.

7. MAF Caretaker Evaluation

a. To receive as a caretaker, the individual must be living with and caring for a child under age 19 who is a citizen or alien lawfully admitted for permanent residence (LPR).

b. If the county dss knows that the recipient has at least one minor child living in the home for whom care is provided, the caretaker requirement is met.

H. Termination of the MAABD Case

1. Send timely notice to propose termination of Medicaid ONLY IF:

a. Information necessary to determine ongoing eligibility is unavailable to agency or is not current, and

b. The information was requested from the recipient according to requirements in this section (VII.), and

c. The recipient did not respond by the deadlines required in this section,

OR

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(VII.H.1.)

d. All procedures in this section were followed and the recipient does not meet the eligibility requirements for Medicaid in any aid program/category. The assistance may be terminated with timely notice prior to the end of the 4 month period if all ex parte requirements have been met.

2. The recipient may rebut the information stated on the timely notice as the reason for termination within the timely notice period. Always use a termination reason code that most accurately describes the reason for ineligibility.