M E M O R A N D U M

IM-27  03/31/98  CONTINUING MEDICAID WHILE SSI IS APPEALED


SUBJECT:
CONTINUING MEDICAID WHILE SSI IS APPEALED
 
DISCUSSION:
This policy addresses continued eligibility for Medicaid of persons who have lost Supplemental Security Income (SSI) due to a determination by the Social Security Administration (SSA) that they are no longer disabled.  These persons may remain eligible for Medical Assistance (MA) throughout the appeal process with SSA, as long as they timely appeal the determination and remain eligible on all other factors.

Persons who are in the appeal process with SSA, but are still receiving SSI benefits are not affected by this policy.

This policy applies only to MA recipients whose SSI terminates when:

  • the termination is due to an SSA determination that the claimant is no longer eligible for SSI because the claimant does not meet disability criteria
 AND
  • the claimant has appealed the SSI disability determination to SSA within 60 days of their decision.
This policy does not apply to someone who:
  • has been determined ineligible for SSI for a reason OTHER THAN disability
 OR
  • failed to appeal an SSI disability determination within 60 days of the SSA decision.
When you receive notice that SSI has terminated due to a disability determination, follow the steps below before closing the MA case:
  1. Investigate eligibility under another type of assistance.  If not eligible under another type of assistance, submit medical information for an MRT decision. 

    2.  
  2. If MRT determines the claimant does not meet disability criteria, contact SSA.  Ask whether the SSI disability determination has been appealed.

    3.  
  3. Based on when and whether an appeal has been made through SSA, do one of the following:
    1. If the disability determination has not been appealed and 60 days have passed since the SSI determination, close the case.

      2.  
    2. If the disability determination has not been appealed and 60 days have not passed since the SSI determination, set a priority to check with SSA at the end of the 60 day period.  If at the end of the 60 days an appeal has not been filed, take action to close the case.

      3.  
    3. If the disability determination has been appealed through SSA, do not close the case.  Set a priority to check on the case periodically to determine the appeal status.  Close the case only when the SSI appeal process has been completed and the claimant has been found not disabled.
The SSI appeal process will be considered complete when the person has had a:
  • Reconsideration of the initial decision;
  • Review by an Administrative Law Judge; and
  • Decision by the Social Security Administration Appeals Counsel.
  OR
  • Fails to appeal a lower level decision to the next higher level within 60 days of that decision.
Some currently closed Medicaid individuals would have remained open had this policy been in effect at the time of their closing. These could include individuals who lost SSI because of changes in the definition of disability pertaining to drug addiction and alcoholism.  If such a case comes to your attention, verify the appeal status with SSA, and if the appeals process has not been completed take prompt action to cancel close the case.
 
NECESSARY ACTION:
  • Review this memorandum with appropriate staff.

    •  
  • Begin following the procedures in this memorandum whenever a Medicaid recipient's SSI payment terminates due to a disability determination.

    •  
  • Verify the appeal status and cancel close any MA case you identify that closed due to an SSI disability determination, if the SSI appeal process has not been completed.
ET/AM
Distribution #6
[ Memorandum Table of Contents ]