1. Expanding Foundations: Non-MAGI
SSI Based Programs
Expanding Foundations: Non-MAGI

2. SSI Related Programs Objectives:
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Objectives:
After this module, Participants will be able to:
Data Enter an SSI mandatory case
Identify program resource limits
Identify Household requirements and data entry for SSI related Non-MAGI programs
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3. Program List SSI - Supplemental Security Income OAP - Old Age Pension
PICKLE
DAC - Disabled Adult Child
QDW - Qualified Disabled Widow(er)

4. Commonalities Benefit Category 2. State-plan Medicaid Resource Limits
$2000 Individual
$3000 Couple
45 days to process, 90 days if disability determination is needed.

5. Commonalities Income limits (except OAP) Income Disregards
$733 Individual
$1100 Couple
Income Disregards
$20 Unearned Income
$65+ ½ (total earned income) -Earned income

6. Earned Income Disregard
Jimmy has $1065/mo. in earned income.
$1065-$65= $ ½ ($1000) = $500
($65 + $500) = $565 is disregarded
$500 is countable towards Non-MAGI.

7. Household
Living in the Home
Case Individual
And Married
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8. Married Individual Demographics Household Relationships
Both sections must be complete and consistent.
Married, Common Law, and Common Law Registered are considered Married.
Domestic Partner and Civil Union are not
Household relationships must be entered and consistent with the Individual Demographics data entry (husband/wife, husband/husband, wife/wife). Again client statement is acceptable unless questionable.

9. SSI Mandatory
All individuals receiving an SSI cash benefit are eligible for Medicaid.
Benefit can be backdated to the day they 1st received SSI.
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10. Let’s enter a case!
You receive notification that an unmarried member has been receiving $733 in SSI benefits since April 18th This is verified through SDX

11. Let’s enter a case! AI a case from 4/18/2016.
Individual is born between 1955 and 1975
Make up a name an SSN
Assume you have an SSN card and Birth Certificate.
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12. SSI Details
Individual Demographics – SSI tab

13. SSI Income
Unearned Income

14. SSI Income
Income Received

15. Run EDBC

16. OAP Covered in Expanding Foundations: Adult Financial
Individuals eligible for OAP AF will receive a MA benefit,
Could be OAP-Med, OAP-HCP, QMB, WAwD or even a MAGI program!
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17. Pickle
Intended to protect SSI’s Medicaid benefit from SSDI initial entitlements or COLAs pushing an individual over the income limit.

18. The Pre-Pickle Program Problem
Jimmy initially received a $752 SSDI benefit in 2016.
He was also under the SSI resource limit, so SSA calculated a SSI benefit.

19. The Pre-Pickle Program Problem
$752 SSDI - $20 (unearned income disregard) = $732. The SSI limit is $733.
Jimmy qualified for a $1 SSI benefit as well, which entitled him to Medicaid
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20. The Pre-Pickle Program Problem
In January 2017 there is a COLA for SSA of 5 percent!
The SSI limit would increase by 5 % ($733 x 1.05 = $769.65) rounded to $770!
Jimmy’s SSDI benefit would increase by 5% ($752 x = $789.60) rounded to $790!

21. The Pre-Pickle Program Problem
SSA re-checks Jimmy’s SSI eligibility. $790 SSDI -$20 = $770. The SSI limit is $770.
Jimmy no longer qualifies for the $1 SSI benefit

22. The Pre-Pickle Program Problem
Jimmy loses Medicaid…

23. The Pickle Person Procedure
The Pickle Program keeps this population on Medicaid if they:
Are eligible for and receiving a Title II benefit
Have countable income and assets below current SSI limits ($2000/$3000)
Submit an application

24. The Pickle Person Procedure
CBMS will check to ensure they client is only over-income because of the Title 2 increase. These are rare occurrences to keep an eye out for around COLAs. A data entry guide is in the book.

25. Disabled Adult Child (DAC)
Protect SSI’s Medicaid benefit from a SSA Disabled Adult Child entitlement pushing an individual over the income limit.

26. Disabled Adult Child (DAC)
A DAC SSA entitlement is for individuals who suffered a childhood disability (prior to age 22).
Because they were unable to collect work credits of their own, they can draw on their parent’s claim…when their parent retires or becomes disabled.

27. DAC Benefit Problem
Terra suffered a childhood disability and was found disabled by SSA at age 14
Terra was unable to work as a result.
At age 18 Terra started receiving an SSI benefit and Medicaid.

28. DAC Benefit Problem
In 2016 Terra’s parents retire, Terra qualifies for a DAC payment of $800 based on her parent work history. SSA automatically uses this income change to re-evaluate SSI eligibility.
$800-$20 disregard= $780 which is over income for SSI.

29. DAC Benefit Problem
Terra loses SSI and SSI Mandatory Medicaid.

30. DAC Medicaid DAC Medicaid keeps this population on Medicaid if they:
Meet the $2000/$3000 resource limit
Would be income eligible for SSI if they did not receive the DAC benefit
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31. DAC Medicaid This is also a rare population.
CBMS will read the DAC benefit from the SSA interface and run income/resource calculations.
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32. Qualified Disabled Widow(er)
Protect SSI’s Medicaid benefit from a SSA Widow(er) entitlement pushing an individual over the income limit.

33. Qualified Disabled Widow(er)’s Burden
Valerie is 52yo and disabled. She is married to Rob who is working and provides for the household.

34. Qualified Disabled Widow(er)’s Burden
Rob dies.

35. Qualified Disabled Widow(er)’s Burden
Valerie would be eligible for SSI and Medicaid but…

36. Qualified Disabled Widow(er)’s Burden
The widow benefit she received from Rob’s work quarters totals $920/mo.
SSA points out she isn’t SSI eligible due to this income, Valerie can’t qualify for SSI Medicaid

37. Qualified Disabled Widow(er)’s Burden
QDW extends Medicaid to this population if they:
Meet the $2000 resource limit
Apply
Would be income eligible for SSI if not for the QDW benefit.

38. Qualified Disabled Widow(er)’s Burden
Again the survivor’s benefit is an income type and is a rare population.
CBMS will check for the income type, Medicare eligibility (disabled), and calculate financial eligibility.

39. SSI Related Programs Objectives: Can you?
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Objectives:
Can you?
Data Enter an SSI mandatory case
Identify program resource limits
Identify Household requirements and data entry for SSI related Non-MAGI programs
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40. Expanding Foundations Non-MAGI
Buy-in Programs
Expanding Foundations Non-MAGI

41. Buy-In Programs Re-visit Objectives:
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Re-visit Objectives:
After this module participants will:
Data Enter a WAwD case.
Explain the coverage difference between Buy-in Programs and State plan Medicaid.
Identify acceptable sources of disability determination for buy-in programs.
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42. Buy-in programs
2 MA categories allow individuals who are disabled, but ineligible for a state plan Medicaid program, to buy-in to Medicaid via a premium.

43. Working Adults with Disabilities
Benefit Category 3
State-Plan with premium
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44. Working Adults with Disabilities
Household
Individual only
Requirements
Disabled and working
Age 16-64
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45. Working Adults with Disabilities
Disability
Can be full or limited from ARG or SSA.
Working
Earned income
Self-employment income
Job attached
Take client statement
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46. Working Adults with Disabilities
No resource limit
Income limit
450% FPL ($4455/mo.) after disregards
$20 unearned disregard.
$65 + ½ (earned income) disregard applies.
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47. Premiums Members on WAwD pay a premium from approval month forward.
Can have Retro Med, no premium is required for retro months.
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48. Premiums Premiums based on countable income Page 84 WAwD premiums 2016
FPL
0%-40%
41%-133%
134%-200%
201%-300%
301%-450%
After Disregards $
$0-$396
$ $1320
$ $1980
$ $2970
$ $4455
Monthly Premium $0
$25
$90
$130
$200
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49. Remember your SSI Case
What must happen to change that person to the WAwD program?
Enter those changes effective today and Run EDBC

50. Children’s Buy-in Children’s Buy-in with Disabilities (CBwD)
Category for children with disabilities whose families are over-income for other Medical Assistance programs
Benefit Category 3
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51. Children’s Buy-in Under the age of 18 300% FPL after disregards
33% of total income is disregarded
An additional $90 earned income disregard
No resource limit

52. Oddities HH composition still uses MAGI rules
Tax filer status
Everything else is Non-MAGI rules
Ineligible for year olds who are working
They should be on the WaWD Program

53. Smaller Premiums CBwD Premiums 2016 FPL 0-133% 134-185% 186-250%%
Premium $0
$70
$90
$120

54. Buy-In Programs Re-visit Objectives: Can you? Data Enter a WAwD case.
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Re-visit Objectives:
Can you?
Data Enter a WAwD case.
Explain the coverage difference between Buy-in Programs and State plan Medicaid.
Identify acceptable sources of disability determination for buy-in programs.
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55. Medicare Saving Programs
Expanding Foundations: Non-MAGI

56. Medicare Based Programs
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Objectives:
After this module participants will:
Perform accurate data entry on the Medicare Expense Page.
Explain the coverage difference between MSP programs and State-plan Medicaid.
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57. MSP Programs Benefit Categories 4 and 5
State contribution to Medicare costs.
May pay for Medicare premiums, coinsurances and deductibles.
Health Insurance coverage remains Medicare.

58. MSP Categories
QMB
SLIMB
QI-1
QDWI
LIS* - Benefit Category 7

59. MSP Categories Eligibility Eligible for Medicare Part A
Income and Resource limits

60. Medicare Part A Part B Part D Hospital/emergency coverage
Typically free
Part B
Primary Care
Has a premium $ based on income
Part D
Prescription Coverage
Variable premium based on plan

61. QMB
Benefit Category 4
QMB individuals have their Medicare premiums, deductibles, co-pays, and coinsurance covered by the state.

62. SLMB and QI-1 Benefit Category 5
SLMB and QI-1 individuals only have their have their Medicare B premiums covered by the state.

63. SLMB and QI-1 What’s the difference?
QI-1 is an expanded income bracket that requires active renewal each year by Congress.

64. QDWI
Benefit Category 5
QDWI individuals don’t have a free part A. They have lost their SSDI and Free Part A because they have too much earned income and are under 65.
QDWI will pay for Part A.

65. But Wait… This population is covered by WAwD.
The program is close to obsolete because of the WAwD category. If a working disabled individuals opts out of WAwD or fails to pay a premium, they might fall into the QDWI category if SSA has identified them as a QDWI eligible.

66. But Wait…
You’ll likely never see it happen…

67. Income and Resource limits
QMB
Income
$1,010 Individual
$1,355 Couple
Resources
$8,780 Individual
$13,930 Couple
SLMB
$1,208 Individual
$1,622 Couple
QI-1
$1,357 Individual
$1,823 Couple
QDWI
$2,000 Individual
$2,690 Couple
$4,000 Individual
$6,000 Couple

68. LIS Low Income Subsidy. Benefit category 7. Managed by SSA.
Provides a partial subsidy for Part D costs and eases the ‘Prescription drug donut hole’.

69. LIS
Approvals for LIS have their info sent to SSA to provide the subsidy.

70. LIS
Because it’s the last program on the hierarchy, it will display denied when applicants are not eligible for any program.

71. Medicare Data Entry
Expenses- Medicare

72. Medicare expenses
Interfaces for existing cases. Data entry required for new cases.
Part A section
Usually Payment method Other and Free Part A
Include approval date- Part A eligibility is required for many programs.
Find this info in BENDEX or SVES.

73. Medicare expenses Part B Section
Enter the actual premium and approval date.
Mnthly Deduc and paid by beneficiary if client pays.
State payment and paid by state buy-in if state is already paying.

74. Medicare expenses Part D tab Billing and Payment tabs
Complete if the client has a Part D premium
Billing and Payment tabs
Complete for cases with FA or LTC-NF. FA will view this as a medical expense until the state pays the buy-in. Entering for LTC will add the expense to the Patient Payment section of wrap-up.

75. Fun with MA categories AI a case
60yo with $1100 SSDI –Verified by Bendex
Part A eligibility
Part B premium of $121.80
Which Category displays in wrap-up?

76. Fun with MA categories Reduce their income to $900/mo
Which Category displays in wrap-up?

77. Fun with MA categories Add any countable resource worth $10000
Which Category displays in wrap-up?

78. Fun with MA categories
Add $1250 earned income
Run EDBC

79. Fun with MA categories
Delete the Earned income and add $1250 unearned income.
Run EDBC

80. Fun with MA categories You’ve received a case with active AF-OAP only
No income or Resources
Add MA and run EDBC

81. Fun with MA categories Add a whole life insurance to your OAP case.
$30,000 face value
$5,000 CSV
Run EDBC

82. Medicare Based Programs
Goal: To understand a group of Non-MAGI programs, and their eligibility rules.
Re-visit Objectives:
Can you?
Perform accurate data entry on the Medicare Expense Page.
Explain the coverage difference between MSP programs and State-plan Medicaid.
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83. Course Evals
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