Adult Medicaid Manual MA-2110 PASSALONG

II. COLA PASSALONG PICKLE AMENDMENT GROUP

A. Eligibility Requirements

1. Currently receives RSDI (Social Security) benefits;

2. Was eligible for and received RSDI (Social Security) and either SSI or State/County Special Assistance (SA) concurrently for at least one month after April 1, 1977 (or is treated as having received them concurrently under 4. below); and

3. Lost SSI or SA for any reason but would currently be eligible if the total amount of all COLAs since losing SSI or SA benefits were excluded from countable income.

4. Individuals who received SSI and then were found retroactively eligible for RSDI are considered to have received SSI and RSDI concurrently. See Example 1 below.

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(II.A.)

5. If passalong eligibility is based on prior receipt of SA (not SSI), the individual must currently reside in an adult care home.

B. Verify Individuals Who Lost SSI or SA Eligibility.

Applicants/recipients need not claim passalong status. Follow instructions below to determine if the individual may be eligible for COLA passalong. However, many individuals may not be able to remember when or if they received SSI or Special Assistance. Fully investigate passalong eligibility in every case where the individual is otherwise over income for CN MAABD because of income from Social Security. If the individual clearly states he has never received SSI or SA, then document in the record that there is no passalong eligibility.

Use the following resources to identify individuals who lost SSI or SA eligibility:

1. SDX - The Medicaid Eligibility Code field indicates the eligibility status. If the code is R, D or W, the individual is ineligible for an SSI payment. SDX will not show SSI terminations prior to 01-01-95. If an SSI termination may have occurred prior to that date, call SSA.

2. EIS produces the 503 Leads Report (DHREJA COLA 503 LEADS) when the RSDI COLA mass change processes. The current report and prior year reports are on NCXPTR. The 503 Leads Report identifies individuals who lose SSI eligibility due to an increase in RSDI benefits. Annual review of COLA passalong eligibility based on these reports is required. However, these reports are incomplete and do not identify many passalong eligible individuals. SSI may have been terminated for a reason other than the COLA but the individual may still be passalong eligible. Such persons will not appear on this report.

3. SSI Termination Report – Refer to MA-1000, SSI Medicaid – Automated Process and EIS-4200, Part Eight.

4. For individuals in assisted living who may have been terminated from Special Assistance, complete an inquiry into the Eligibility Information System.

C. Verify and Document the Following Factors for Potential Passalong Eligibility.

1. The date SSI or SA benefits were terminated on or after April 1977.

2. The current amount of the a/r’s RSDI.

3. The amounts of all RSDI COLAs the a/r received since SSI or SA was terminated.

4. Contact the local Social Security Office if unable to verify benefits using BENDEX, SDX, SOLQ, case record or SSA letter.

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D. Once You Determine That the Individual is Passalong Eligible Take the Following Steps To Determine the Countable RSDI Income.

1. Disregard any COLAS received after SSI or SA was terminated for any reason from the current RSDI income for the a/r.

2. If there is a financially responsible person (spouse or parent) who receives Social Security benefits, also disregard all COLA’s received by that person since the a/r was terminated from SSI or SA.

3. The result is the countable RSDI income.

NOTE: Refer to the current chart in II. F below for assistance in deducting all Social Security cost of living adjustments (COLA) received since the last month in which he or she was eligible for both Social Security and SSI or Social Security and SA.

E. Add the Countable RSDI Income to Other Countable Earned and Unearned Income and Compare to the Current SSI or SA Income Limit. (Use the 1/3 Reduced Income Limit If Appropriate.)

1. If the countable income is below the current SSI or SA income limit, continue to evaluate as categorically needy. This person is eligible under passalong.

2. If the countable income is above the current SSI or SA income limit, the individual is not eligible for passalong. Evaluate as medically needy. DO NOT disregard COLAs. This person is ineligible under passalong. If ineligible for passalong count current RSDI income.

EXAMPLE 1: (COLA Passalong) Jane, age 55, lives alone in her own home in 2011. Her countable assets are less than $2,000. She receives RSDI benefits in the amount of $916 a month in 2011, which is over the Categorically Needy income limit for Medicaid of $908 a month. She has been told by DSS that she has a large Medicaid deductible she must meet prior to Medicaid authorization. Jane applied for RSDI and SSI in October 1985, alleging disability beginning October 1984. She was approved for disability in October 1986 as of her alleged onset date. She was initially paid SSI for October 1985 through December 1986 under SSA procedures which normally pay SSI before Title II (in order to provide Medicaid eligibility).

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She received her first RSDI check in December 1986, which caused her SSI to terminate at the end of December 1986. She also got back RSDI benefits during the same time period which were reduced by the amount of SSI she had received. Her regular RSDI monthly payment exceeded the income limit for SSI. Disregarding RSDI COLAs since the 1986 SSI termination, multiply $908 x .499 (the percentage for 1986 SSI terminations from the chart in II F below). This leaves $453 which is under the 2011 SSI income limit. Jane is Medicaid eligible based on COLA passalong (but not SSI eligible).

EXAMPLE 2: (COLA Passalong) Joe has lived in an assisted living facility since 1990. He is 72 yrs old in 2011 and has received Social Security since 1985 on his own record, first disability benefits, now retirement. He has no assets. In 2011 he receives $950/month in RSDI benefits. He started getting Special Assistance (SA) to help pay his rest home bill in 1990. He started getting income of $350/month from a private pension in 1995, which is the amount he still receives. The pension income caused his SA (and therefore Medicaid) to terminate as over income in July 1995. He has no other income. Multiplying Social Security COLA’s since July 1995 to his 2011 RSDI check equals $646 ($950 x .680 - see the chart in II F below). $646 plus $350 is $996, minus $20, equals $976, which is under the 2011 SA income limit. Joe is eligible for Medicaid under the COLA passalong.

EXAMPLE 3: (COLA Passalong) In 2011, Jane lives at home with husband Joe. Joe is 75 years old and gets RSDI retirement of $675/month. He never received SSI. Jane is age 70 and receives $585/month in RSDI benefits. (Both figures include Medicare premiums). Their joint income of $1,260 is over the MAD categorically needy income limit for couples of $1,226 even after subtracting the $20 disregard. Jane received both RSDI and SSI until 1991 when she married Joe, which made her ineligible for SSI beginning in 1991 based on their combined income. Multiplying both Joe and Jane’s COLA’s since Jane’s SSI terminated ($585 plus $675 equals $1,260 x .604 - see the chart in II F below) and rounding down equals $739, then subtracting $20, leaves $761, which is under the SSI couples’ income limit of $1,011 for 2011. Jane, but not Joe, is eligible for Medicaid under the COLA passalong because she is the one who received SSI.

F. Reduction Factors for Calculating Medicaid Eligibility Under the Pickle Amendment During 2011

If the last month in which a person received SSI while, or immediately prior to, receiving Social Security was in any of the periods in the chart below, multiply the present amount of his Social Security by the corresponding factor to obtain the current countable COLA Passalong income:

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(II.F)

If SSI terminated during Multiply Year 2012 Social Security income by:

G. Documentation

Use DMA-5150, Documentation of Passalong Eligibility or Ineligibility, to document whether or not the individual is passalong eligible. If eligible as passalong, code the individual as “PC” in the Individual Special Use field on the individual level in EIS. If you find an individual who is eligible for passalong due to loss of SA and who is currently residing in an adult care home, contact the EIS Unit for procedures to follow to put this person in EIS.

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H. Redeterminations

At subsequent reviews, determine if the individual still qualifies as passalong. Evaluate the income of the recipient. If countable income after deducting COLAS results in ineligibility for SSI or SA, the individual is no longer eligible as COLA passalong. Evaluate under other passalong categories.