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Staff Tools | OSIP Program Manual | WG.9
Protected Eligiblity
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DHS home | SPD
Staff Tools | OSIP Program Manual | WG.9
Protected Eligiblity
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This worker guide is not policy. It is intended to help workers determine if an individual has protected eligibility for OSIPM. This worker guide is a work-in-progress and will eventually include information on all the protected eligilbity groups.
Disabled adult children (DAC) Pickle Amendment Widows/Widowers Zebley children Section 1619(b) of the 1987 SSA legislation provides for continued Medicaid eligibility for individuals whose incomes are too high to qualify for an SSI cash payment, but are not high enough to offset the loss of Medicaid or publicly funded attendant care. Individuals will be eligible for 1619(b) protected Medicaid status if the sole cause for SSI payment cessation is increased earnings over the break-even point.
SSA determines 1619(b) status. In order to qualify for 1619(b) an individual must meet all of the following:
SSA will ask the person if they need Medicaid in order to maintain their employment. It is important that they answer yes to that question. If they do not, they will not be determined eligible for 1619(b).
A person who is determined to be 1619(b) eligible is assumed eligible for Medicaid (461-135-0010, 7, b). This means that the person will receive OSIPM for as long as they are 1619(b) eligible. You do not have to worry about resources. You just need to check that the client is still 1619(b) eligible.
To determine that a person is 1619(b) eligible, you need to look at the ‘med test’ area on BEIN (see below). If the med test area is coded with an A, B or F, the client is 1619(b) eligible.
To access this screen, you can type in "webm,find,ssn" on the mainframe and then place a character next to the Bendex dot. Enter [F13].
BEIN
To monitor a 1619 (b) case:
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Section 1634(c) of the Social security act and 42 U.S.C (United States Code) 1383c provide Medicaid eligibility for Disabled Adult Children (DAC). In order for an individual to qualify for this program, they must meet the following eligibility components:
Clues that a person might be DAC eligible. These are just clues. You can not be certain that a person meets the criteria as a Medicaid protected DAC unless all eligibility components have been verified.
It is important to note that SSA has their own eligibility criteria for individuals they refer to as DAC’s or CDB’s (Childhood Disability Beneficiaries). When determining eligibility for a Medicaid protected DAC, unless all eligibility components can be verified by other means, SSA must be contacted and asked specific questions related to eligibility for the program we offer. The specific questions staff should ask SSA are as follows:
If the answer to each question listed above is yes, staff can look at DAC eligibility. The client must ALSO meet the other eligibility requirements in order to be considered a Medicaid protected DAC.
Other eligibility requirements the individual must meet:
This means, they must have resources within the SSI limit ($2000 for an individual). They must meet residency requirements, disability requirements etc. It is possible for an individual to lose their DAC entitlement based on these other requirements. However, do not consider the level of the DAC's income as long as they are receiving SSB based on a parent's claim, when determining eligibility.
Reasons that a DAC might lose their eligibility include:
Note: Sometimes the individual will begin receiving both benefits under their own SSN and an adjusted amount of DAC benefits. In that case, the individual’s SSN followed by an “A” code will have a CP P-st (pay status) on BEIN, and the DAC SSN followed by a “C” code will have an AD P-st. The AD indicates the payment was adjusted for dual eligibility, and the individual continues to receive DAC payments and be DAC eligible.
Cases that have been determined to meet DAC status should be reviewed yearly to determine that the individual continues to meet ALL the eligibility factors for a Medicaid Protected DAC.
When an individual is determined to meet all the eligibility components as a Medicaid Protected DAC, ACCESS should be narrated to clearly indicate how the eligibility criteria have been verified. A person who has met the requirements as a Medicaid Protected DAC is considered deemed eligible. This means that we protect their Medicaid eligibility from income, but they must meet all other eligibility factors to be considered eligible. An individual who is determined to be a Medicaid protected DAC does not have to contribute towards their cost of services. If a person loses their DAC status, they would need to qualify for OSIPM under a different program.
An individual who loses SSI for a reason other than those listed above, would not be eligible for Protected Medicaid under DAC criteria. If they lost SSI for one of the following reasons, check eligibility for Medicaid under the appropriate rule:
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History. Representative J. J. Pickle introduced Public Law 94-566 to Congress to deal with the situation where a client receiving SSI has a minimal increase in income that results in the unintended consequence of losing his or her SSI and Medicaid eligibility. This Public Law is therefore called the Pickle Amendment. Congress provided for the Pickle exception because they realized that a client who was formerly eligible for SSI could not obtain or afford medical coverage just because of a small increase in income.
Requirements. In order for the client to meet the Pickle requirements for OSIPM, all of the following must be met:
The Benefit of Being Pickle Eligible. When a Pickle-eligible client needs long-term care services, he or she does not need to pay a liability when in a waivered service setting or in certain mental health settings (see 461-160-0610). However, he or she will need to pay a liability in other care settings (for example, in a nursing facility).
Determining Pickle Eligibility. Clients who have never received SSI cannot be Pickle eligible. If the information is not available on the W204 screen, the eligibility worker will need to contact Social Security to find out what month the client both received SSI and was eligible for SSB. If the SSB amount from that month is known, no Pickle calculation is necessary. Use the SSB from that month and add it to the client’s current income to see if the client’s income exceeds the SSI standard.
Example 1: Gloria was eligible for both SSI and SSB in June 1999. Her SSI terminated and she has an award letter verifying that she received $648 SSB beginning in July 1999. The SSB that she receives now ($825) is her only income. The current SSI standard is $674 + $20 (standard deduction) = $694. The $648 SSB that Gloria was eligible for in the month that she also received SSI in 1999 is less than $694, so she is Pickle eligible.
In many cases, the amount of SSB that was received in the month when the client was simultaneously eligible for SSI is not known. When the amount of SSB from that month is unknown, the eligibility worker must use the chart from 461-135-0780 to calculate the amount. In other words, the current SSB amount must be “Pickled” to find out what it used to be. The “Pickled” amount of SSB plus the client’s other income (countable unearned and adjusted earned) cannot exceed the current SSI standard plus $20.
Example 2: Horace last received SSI in March 1978 when he was eligible for both SSI and SSB. He currently receives $928 SSB. He also has a private pension of $295.
From the chart, we see that the relevant multiplier is .338. $928 X .338 = $313.66 (round down to $313). Next, $313 + $295 (Horace’s other countable unearned income) = $608. The current SSI standard $674 + $20 = $694 and $608 is less than that standard, so Horace is Pickle eligible if he meets all other OSIPM criteria.
Example 3: Elsie last received SSI in April 1993 when she was eligible for both SSI and SSB. She currently receives $790 SSB. She also earns $265 per month answering the phone part time for her church.
From the chart, we see that the relevant multiplier is .683. $790 X .683 = $539.57 (round down to $539). After allowing the $65 earned income deduction and ½ of the remainder, there is $100 adjusted earned income to count. $539 + $100 = $639. The current SSI standard $674 + $20 = $694 and $639 is less than that standard, so Elsie is Pickle eligible if she meets all other OSIPM criteria.
Example 4: Alvin last received SSI in June 2004 when he was eligible for both SSI and SSB. He currently receives $1350 SSB.
From the chart, we see that the relevant multiplier is .885. $1350 X .885 = $1194.75 (round down to $1194). The current SSI standard $674 + $20 = $694 and $1194 exceeds that standard so Alvin in not Pickle eligible.
Computer System Coding. When you determine that a client meets the criteria for protected eligibility as a Pickle, code the case with an OSS case descriptor and a need/resource of SSB for the current SSB amount. Do not code the Pickled SSB amount.
Example of coding for client who is currently Pickle eligible:
If you find a client who does not meet the Pickle criteria but most likely will in the future (for example, the Pickled income is close to the limit but just slightly over), use the PKL case descriptor. This will alert field staff that this client received SSI and lost it after April 1977, that the client was eligible for both SSI and SSB in the same month and that the case should be looked at for Pickle eligibility in the future. Be sure to narrate the information in Oregon ACCESS.
Example 5: Theodore last received SSI in October 1979 when he was eligible for both SSI and SSB. He currently receives $985 SSB. He also has a private pension of $360.
From the chart, we see that the relevant multiplier is .358. $985 X .358 = $352.63 (round down to $352). Next, $352 + $360 (Theodore’s other countable unearned income) = $777. The current SSI standard $674 + $20 = $694 and $712 is more than that standard, so Theodore is not Pickle eligible. Code his case with a PKL case descriptor because his income is only $18 over, so he is likely to become eligible in future years.
Example of coding for a case that may have future Pickle eligibility:
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Narration is the Key. For any client determined Pickle eligible (OSS) or potentially Pickle eligible (PKL), be sure to clearly narrate the determination. This makes it possible for anyone else reviewing the case to see how the determination was made and prevents questions about eligibility in the future. For example, you might narrate:
Follow Up After Pickle Determination. Clients who have been determined Pickle eligible can lose the status when their situation changes. For example:
For this reason, it is very important to check the client’s resources at each review. Also, when the client has changes in his or her situation that could impact the client’s countable income or resources, re-check the Pickle calculation.
Remember to Check All Protected Eligibility Groups. An individual who does not meet the Pickle criteria above, would not be eligible. However, if they lost SSI for one of the following reasons, check eligibility for Medicaid under the appropriate rule:
This is a protected group for an individual with a disability who was receiving SSI, but his or her spouse or ex-spouse passed away, and the resulting amount of Social Security widow/widower’s benefits based on the deceased spouse’s work history caused the SSI to terminate.
History. This protection was established by Congress effective July 1, 1988. Therefore, individuals cannot be eligible prior to that date. However, because it is only for individuals who are not eligible for Medicare Part A, it only affects individuals who have recently begun receiving Social Security benefits.
Requirements. The individual must not be eligible for Medicare Part A (Hospital coverage).
The individual must have received SSI, but lost the SSI when his or her spouse or ex-spouse passed away because the resulting Social Security widow/widower’s benefit exceeded the SSI amount.
The individual is deemed to meet the SSI income limit, but must continue to meet all other SSI eligibility criteria (including resources).
There is no longer any age limit for this protected group.
Benefits of Being Eligible. When a protected widow/widower needs long-term care services, he or she does not need to pay a liability when in a waivered service setting or in certain mental health settings (see 461-160-0610). However, he or she will need to pay a liability in other care settings (for example, in a nursing facility).
Determining Widow/Widower Eligibility. These individuals are usually receiving SSI and Medicaid when their spouse dies. When the widow/widower Social Security benefits begin, the amount exceeds the SSI amount. This causes the SSI to terminate. If the individual is not eligible for Medicare Part A, authorize protected eligibility under this policy.
Computer System Coding. Code eligible cases on CMS with WDC and NCP case descriptors, and the individual’s current Social Security benefit amount. The WDC case descriptor prevents the case from going NA.
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Narration is the Key. For any widow/widower determined eligible, be sure to clearly narrate the determination. This makes it possible for anyone else reviewing the case to see how the determination was made and prevents questions about eligibility in the future. For example, you might narrate:
Follow Up After Widow/Widower Determination. Widows/widowers who have been determined eligible can lose the status when their situation changes. For example:
Remember to Check All Protected Eligibility Groups. An individual who does not meet the widow/widower criteria above, would not be eligible. However, if they lost SSI for one of the following reasons, check eligibility for Medicaid under the appropriate rule:
This is a protected group for SSI children who lost eligibility under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, commonly known as Welfare Reform.
History. The Welfare Reform legislation of 1996 made it more difficult for children to meet the SSI disability requirements; especially those with mental disorders. Because SSI criteria became more stringent, many children lost their SSI eligibility. The first court case to contest the new law was the Zebley case. As a result, the Balanced Budget Act of 1997 was passed which offered protection to this group under Section 4913 of the Act. The purpose is to protect SSI eligibility for children who were already determined eligible for SSI before Welfare Reform and who might not be eligible under the new criteria. For example, children with cognitive impairments or autism most likely would not qualify under the new criteria.
Requirements. A child (under the age of 18) must have met the SSI disability criteria on August 22, 1996, and as a result received or was eligible to receive SSI. The child continues to be deemed eligible for SSI as long as the child continues to meet all OSIPM eligibility requirements. The protection ends when the child turns age 18.
Benefits of Being Eligible. A child with this protected eligibility can continue to receive OSIPM until the end of the month in which he or she turns age 18 even if the child no longer meets the SSI disability criteria.
Determining Zebley Child Eligibility. Determine that the child is currently under age 18. Determine that the child received or was eligible to receive SSI on August 22, 1996. Verify that all other OSIPM eligibility criteria are met, including deemed assets from the child’s parents in the household.
Computer System Coding. Code eligible cases on CMS with SDC, ECS and NCP case descriptors, and an SSI amount of zero with no SIP. The SDC code prevents the case from going NA due to excess income.
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Narration is the Key. For any Zebley child determined eligible, be sure to clearly narrate the determination. This makes it possible for anyone else reviewing the case to see how the determination was made and prevents questions about eligibility in the future. For example, you might narrate:
Follow Up After Zebley Child Determination. Zebley children who have been determined eligible can lose the status when their situation changes. For example:
For this reason, it is very important to check the client’s situation at each review. The child must continuously meet all OSIPM eligibility factors.
Remember to Check All Protected Eligibility Groups. An individual who does not meet the Zebley child criteria above, would not be eligible. However, if they lost SSI for one of the following reasons, check eligibility for Medicaid under the appropriate rule:
