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Staff Tools | GA Program Manual | WG-4 Interactions
Between GA and Presumptive Medicaid
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DHS home | SPD
Staff Tools | GA Program Manual | WG-4 Interactions
Between GA and Presumptive Medicaid
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GA disability decisions are not bound by presumptive Medicaid (PM) decision and vice versa. However, it is important to understand the procedure that should be used in relation to the PM process.
Presumptive OSIPM decision has been made for GA eligible client:
Presumptive OSIPM decision has not been made:
The GA disability impairment criteria is more restrictive than presumptive OSIPM disability impairment criteria for individuals under the age of 55. Clients meeting GA impairment criteria should meet the presumptive impairment criteria, but some differences exist that may will result in GA clients being ineligible for presumptive OSIPM.
SSA’s decisions are binding for GA at the point the client is denied at the ALJ Hearing Level. To be found eligible , the client must reapply and have a new or worsened condition and re-apply for SSI only. Client may still be eligible for presumptive OSIPM.
Example 1
Karla is a GA applicant (not former GA or currently receiving Presumptive OSIPM) with an SSA denial two years ago. Karla is claiming a new condition that meets GA impairment criteria and meets all other GA eligibility factors.
Procedure
Example 2
Gary is a GA applicant (not former GA or current OSIPM/Presumptive) with an SSA denial within the last 12 months, is in an administrative appeal process and claiming a worsened medical condition. Gary meets GA impairment criteria and all other GA eligibility factors.
Procedure
Example 3
Sue is a GA applicant who was on the GA program when it ended 1/31/03 (she has not yet been submitted for a presumptive OSIPM decision). She is currently receiving presumptive OSIPM. Sue has an SSA reconsideration denial less than 12 months ago, in which SSA did not make a decision within 90 days of GA DOR and is waiting for her SSA hearing to be scheduled. Sue meets all GA eligibility factors.
Procedure
Example 4
Frank is a GA applicant and is currently receiving presumptive OSIPM (not former GA). Frank has never applied for SSA benefits until now. Frank meets all GA eligibility factors.
Procedure
Example 5
Kelly is a GA applicant and is currently receiving presumptive OSIPM (not Former GA). She is currently in appeal status at the Appeals Review Council level with SSA. Kelly is not eligible for GA as the SSA ALJ denial is binding. She must have a new or worsened condition to be eligible for GA in the future.
Procedure
Example 6
Bonnie and Bob are married and neither of them has applied for SSA benefits until now. Once the application is made, Bonnie's SSA claim shows potential eligibility for SSI and SSDI, while Bob has no work history and is only potentially eligible for SSI.
Procedure
Determine whether both Bonnie and Bob meet the GA impairment criteria.
Example 7
George has been denied for GA because he is 40 and does not meet an impairment listing. The MRT suspects that George may equal a listing.
Procedure
| Eligibility Factor | General Assistance | Presumptive OSIPM |
| SSI Application | Required | Not required |
| SSDI Application | Individual ineligible | Will not make the individual ineligible |
| Medical Effective Date | Date of request | Up to 90 days prior to date of request if eligible and claiming unpaid medical bills |
| Age | Must be 18-64 or 65 & older if a disabled
qualified non-citizen |
No age requirements |
| Married Couple | Both must meet impairment criteria | Individual may qualify even if spouse is not disabled |
| Income/Payment Standards | $314/individual |
$580.70/individual $869/couples 300% of SSI ($1692) for individuals receiving waivered services |
| SSA Binding Decision | Ineligible at the time the ALJ/Hearing Officer renders a denial decision | Ineligible at the time the Appeals Council renders a denial decision (see OSIP WG-4 for more information) |
| Special Needs | Not eligible for:
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Eligible for each of these |
