SI DAL01730.007 SSA/State Agreements under Section 1634 (Louisiana)
Louisiana entered into an agreement under Section 1634 of the Social Security Act with the Social Security Administration (SSA) for SSA to make Medicaid eligibility determinations. Supplemental Security Income (SSI) recipients who receive an SSI cash payment, are in N24 payment status (GN 02604.405 and GN 02604 .440), or are Section 1619(b) recipients automatically have Medicaid eligibility unless:
See SI 01730.040 through SI 01730.048 for a discussion of the Medicaid eligibility limitations, including transfer of resources (TOR).
Individuals converted as essential persons, regardless of the State of conversion, are eligible for Medicaid in Louisiana until they become potentially eligible for SSI (e.g., age 65).
B. Procedure — District Office
When an individual files for SSI, the SSA interviewer will provide the applicant with the following information:
If the claimant is found eligible for SSI payments and meets all other requirements in SI 01730.040 through SI 01730.048, the claimant will also be eligible for Medicaid.
The SSI recipient should report all address changes to SSA in order to receive the Medicaid card on time and to receive notices including notice of changes in eligibility, notice relative to changes in covered services, or notices relative to changes in the Medicaid program.
The SSI recipient will receive a permanent plastic swipe Medicaid eligibility card (referred to as Health Network for Louisiana) in the mail from the Louisiana Department of Health and Hospitals (DHH), Bureau of Health Services Financing (BHSF), within 40 days after receipt of the first SSI check.
The card will contain a unique 16-digit card control number, recipient name, issue date and bank identification number.
If the Health Network for Louisiana plastic Medicaid card is not received timely or lost/damaged, the SSI recipient should contact the local BHSF Medicaid office.
If the SSI recipient has unpaid medical expenses incurred in the three months prior to the month of application (shown in the AP field) for SSI, refer the SSI applicant to the local BHSF Medicaid office. BHSF may be able to cover these unpaid expenses. Medicaid eligibility for this 3-month prior period requires a Medicaid application with DHH/BHSF, and the eligibility decision will be made by DHH/BHSF.
Note: The SSI recipient will be contacted by DHH when the Unpaid Medical Expenses (UE) field on the SSR is coded with a "Y" and transmitted to Louisiana via the State Data Exchange (SDX).
DHH is responsible for determining what services are covered by Medicaid and for processing bills for services charged to Medicaid. Providers with the necessary equipment can swipe the plastic Medicaid card to access Medicaid eligibility information.
C. Procedure — Louisiana Department of Health and Hospitals
Although SSA determines eligibility for most SSI recipients, Louisiana DHH is responsible for administration of the Medicaid program (e.g., the State issues Medicaid cards, determines what medical services are covered, and pays providers). DHH also makes the Medicaid determination on TOR, AOR, TPL, and Medicaid trust cases.
Medicaid eligibility cards for SSI recipients who are Louisiana residents are issued by DHH based on the eligibility information given the State DHH office by SSA on the SDX tape. A plastic Medicaid card is sent to new SSI recipients within 40 days from the time the individual is in C01/M01 pay status on the SSR. A monthly Medicaid card is not issued.
Reinstated SSI recipients do not receive a new Medicaid card; their eligibility is simply reinstated on DHH’s Medicaid eligibility file.
If the SSI recipient is not on the SSR/SDX or the information is incomplete, see manual Medicaid certification procedures in SI DAL01730.007E.
D. E02 Month and Medicaid Entitlement
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 provides that SSI payments may only begin as of the first day of the month following the later of (1) the date of the application is filed or (2) the date the individual becomes eligible for such benefits (SI 00601.009). As a result of this policy, cash SSI payments are not paid for the first month of SSI eligibility (i.e., the E02 month). Since no SSI cash payments are paid for the E02 month, no Medicaid certification is made to DHH by SSA. If death occurs in the filing month, curtail development, input death termination, and refer any inquiry about medical expenses to DHH (SI 00601.010E.4).
DHH receives information on the E02 payment status month via the SDX. In most cases, DHH automatically recognizes the E02 month and provides Medicaid for the month. Please note that this is a DHH agency decision and does not affect or change the SSI program policy or procedures. In some rare cases, the E02 month is not identified by DHH. In these cases, the SSI recipient should contact the local DHH/BHSF Medicaid office for resolution.
E. Manual Medicaid Certification Policy
A Louisiana DHH Certification for Medicaid Eligibility, SS-RVI-303, should be routinely prepared for situations listed below when SSA makes the Medicaid determination but a correct or complete SSI record cannot be provided to DHH:
Systems limitations cases;
Closed period(s) of SSI entitlement;
Intervening period(s) of SSI entitlement; or
SSI applicant dies (See SI DAL01730.007F.4 for qualifying circumstances); or
SSI claimant/reinstated recipient moves out of Louisiana before payment is initiated.
SSA should never certify Medicaid coverage for any month of SSI ineligibility (e.g., N04), the E02 month, the 3-month prior period, or a month of non-SSI cash payment (e.g., E01, N01) unless the non-cash month is a Section 1619(b) month or is PSY N24. For months of SSI ineligibility for a cash payment/1619(b)/N24, refer the client to the local DHH/BHSF office for possible coverage under another Medicaid category administered by DHH.
F. Manual Medicaid Certification (MMC) — DO Procedure
For the situations listed in SI DAL01730.007E, the DO should complete Parts I and III of the SS-RVI-303 (See Exhibit 1) and mail the original copy to:Hammond Region Office
121 Robin Hood Drive
Hammond, LA 70403
Attn: Faye Williams
Certify to DHH only for the period the SSI recipient is/was a resident of Louisiana and received an SSI payment or was eligible for 1619(b), or was in PSY N24. If the recipient resided outside of Louisiana anytime during the period of eligibility and SSA determines Medicaid eligibility in that State (i.e., a 1634 State), call the servicing FO for the out-of-State residence. Have the former SSA DO certify Medicaid to their respective State agency using their State-specific procedures.
A copy of the SS-RVI-303 should be in the SSI folder (if available). A third copy may be placed in a central DO location to facilitate control per 1.a. below.
In addition, take the following actions, as appropriate:
1. Systems Limitation Case
Control the case so that changes in eligibility, payment status, and residence (e.g., becomes N04 or moves out of Louisiana) can be reported on the SS-RVI-303, Parts I, II and III, to the local BHSF Medicaid caseworker.
Maintain control until the case is successfully established on the SSR or a new SS-RVI-303 is sent to cease eligibility in Louisiana.
When the SSI recipient is entitled to Part B buy-in, but the buy-in has not been effectuated, send a HCFA-1957 (Report of State Buy-In Problem) to Center for Medicare and Medicaid (CMS) Central Office per HI 00815.088 and HI 00930.000. Include a detailed explanation for any periods of buy-in based on SSI payments not reflected on the SSR.
2. Closed Period of Eligibility
In closed period of eligibility cases, DHH receives only one SDX transaction which indicates the record is in non-pay status. Although SSI benefits were paid for a retroactive period, DHH is not able to establish Medicaid eligibility for the closed period of SSI eligibility and payment because DHH extracts data from the SDX that only indicates the current non-pay status.
Indicate on the SS-RVI-303 all periods of SSI payment in Louisiana in the retroactive period.
3. Intervening Period(s) of Eligibility
DHH now picks up retroactive period(s) of Medicaid eligibility in cases when the SDX transaction reflects a start pay-stop pay-start pay payment history. This is a change from past procedures. However, the timing must be that the case is in C01 when initially received by DHH.
If the case is not in C01 when initially received by DHH, DHH is not able to establish Medicaid eligibility for the closed period of SSI eligibility and payment in Louisiana. Therefore, a manual Medicaid certification would be needed.
Indicate on the SS-RVI-303 all periods of SSI payment in Louisiana in the retroactive period.
4. SSI Claimant Dies
If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is no one to receive the underpayment, but there are unpaid medical expenses alleged either on the application or by an interested party, complete development with the proper applicant (GN 00204.003) to determine SSI eligibility (i.e., disability and all non-disability requirements). If you do not have a proper applicant, complete the SS-RVI-303 listing the name and address of the “interested party” and refer the case to the State for a Medicaid determination. DO NOT indicate SSI eligibility on the SS-RVI-303 since we are not making an SSI determination.
If SSI eligibility is found so that payment would have been due, prepare an SS-RVI-303 with the additional information required in d. below.
If a claimant dies after SSA receives the signed SSI application and death occurred after the month of filing, but before adjudication, and there is someone eligible to receive the underpayment, complete development to determine SSI eligibility for payment (i.e., disability and all non-disability requirements). See SI 00601.010E. when IAR is involved.
If SSI eligibility is found, prepare an SS-RVI-303 with the additional information required in d. below.
If there is a protective statement (oral or written), but the claimant dies before SSA receives a signed application for SSI, and an underpayment may be due (including IAR) someone eligible to receive the underpayment may file an SSI application (GN 00204.005). See SI DAL01730.007K, second paragraph, if these conditions do not exist.
Complete development to determine SSI eligibility (i.e., disability and all non-disability requirements). If SSI eligibility is found, prepare an SS-RVI-303.
In preparing the SS-RVI-303 for any of the three situations in a.-c. above,
Cross out the first and last sentence in the introductory paragraph of Part I;
Provide the Medicaid caseworker with the name and address of the "interested party" or the person receiving the underpayment in the Address section; and
Annotate the Remarks section with "If alive, claimant would have been found Medicaid eligible" and the date of death.
5. SSI claimant/reinstated recipient moves out of state before payment is made
Only one State receives an SDX file at a time. There are situations where an SSI claimant moves out of Louisiana before payments are started. Since the change of address/residence will include a new State and County Code, the SDX file will be sent to the new State of residency. Therefore, DHH will not be aware that there were SSI payments for a period of time covering residency in Louisiana.
SSA DOs will become aware of these cases when an inquiry is received from the SSI recipient or from DHH. In these cases, prepare an SS-RVI-303 only for the period of SSI payment and residency in Louisiana. Indicate in Remarks the date the SSI recipient moved out of Louisiana.
G. Manual Medicaid Certification — DHH Process
Upon receipt of the SS-RVI-303, the BHSF Medicaid caseworker will certify Medicaid eligibility to the State Medicaid fiscal intermediary (FI) which will issue a plastic swipe Medicaid eligibility card within 48 hours. The manually-certified Medicaid card should be received by the SSI recipient within 5 days after certification by the parish caseworker. Medicaid eligibility will be established on the Medicaid eligibility file at the same time that the card is issued.
Once a case is manually certified for continuing Medicaid eligibility, DHH will continue to provide Medicaid coverage until:
DHH is notified by SSA via the SS-RVI-303, Parts I, II and III, in a systems limitation case that the named SSI recipient is no longer entitled to SSI or has moved out of Louisiana.
H. Emergency Need for Medicaid Card — Policy
An initial plastic swipe Medicaid card is sent to new SSI recipients within 40 days of the time the individual is in C01/M01 pay status in Louisiana. Reinstated Louisiana SSI recipients should have their Medicaid eligibility reactivated within 48 hours. If the SSI recipient has been in C01/M01 pay status for less than 40 days in Louisiana but a medical emergency exits, follow the procedure in I. below to provide certification of current month Medicaid eligibility only.
A medical emergency is a situation that would endanger a person's life if medication or medical attention is not provided immediately.
Note: A request for Medicaid certification for a retroactive period is not considered a medical emergency.
I. Emergency Need — District Office Procedure
If the criteria in SI DAL01730.007H is met, the DO should:
Prepare an SS-RVI-303, Parts I and III, with the required information;
Obtain approval from an operations supervisor/MSS (or above) for use of the emergency procedure. The SSA official authorizing the appropriateness of the emergency certification should sign in Part III;
Call the State Department of Health and Hospitals/BHSF in Hammond, LA at (985) 543-4303 and ask for Faye Williams. In the event Ms. Williams is not available call (985) 543-4006 (Main Office Number) to request assistance. Note: A telephone call to DHH is appropriate only in an emergency situation.
Provide the State DHH/BHSF Medicaid office with the reason for the medical emergency, the information on the SS-RVI-303, and any special instructions needed for recipient contact; and
On the same day as the telephone call, mail the original copy of the completed SS-RVI-303 to:Hammond Region Office
121 Robin Hood Drive
Hammond, LA 70403
Attn: Faye Williams
Write the name of the person you contacted at the State office in the "ATTN" line at the top of the SS-RVI-303. The "Louisiana DHH Certification for Medicaid Eligibility" form is the folder documentation required by the Louisiana Department of Health and Hospitals. Place a copy in the SSI folder, if available.
J. Emergency Need — State Procedure
The State Medicaid Office of the Louisiana Department of Health and Hospitals, will:
K. Individual Dies Before Filing for SSI
If an individual did not file an SSI application with SSA before death, but an oral inquiry/protective writing exists, and an underpayment would be due a parent/spouse or IAR State, then pursue an application and complete development for payment of the underpayment and Medicaid eligibility (GN 00204.005). See SI DAL01730.007E. for manual Medicaid certification instructions.
If an oral inquiry/protective writing does not exists or one exists but no underpayment would be due (e.g., death in the E02 month), or no one is eligible for an underpayment (if one were to exist), immediately refer an interested party inquiring about Medicaid coverage for the decedent's unpaid medical expenses to the local Bureau of Health Services Financing, Medicaid of Louisiana office. The 3-month period of retroactivity for coverage ends with the date an application for Medicaid is filed with DHH on behalf of the deceased individual, not with the date of death.
L. Nonreceipt of Medicaid Card or Medicaid Coverage not on State Records
When an SSI recipients in C01, M01, M02 with cash payment, Section 1619(b), N24, or protected payment status contacts the SSA office alleging (1) nonreceipt of the initial plastic Medicaid card in 40 days of receipt of the first SSI check and no manual Medicaid certification is required per E. above, or (2) that Medicaid coverage is not on DHH records, then verify that the correct address, zip code and State/County code are on the SSR.
The State/County code in the ADDR and CMPH segments of the SSR should start with ?19? for Louisiana residents. If protected payments are being paid using the G-K systems procedures, the SCR field in the DUPR segment should have 5 zeros (SM 01305.640 and MSS 98N084, dated 04/23/98.)
If the address data on the SSR is incorrect, transmit the correct information to the SSR. This information will be sent to DHH via the SDX. Also, take action to complete whatever additional development (e.g., LA) is required by SSI.
If the SSR is correct and the State/County code has not changed in the last 40 days, refer the recipient to the local DHH/BHSF Medicaid office.
M. Referrals to DHH for Non-SSI Recipients
As discussed in SI DAL01730.007A, SSA makes Medicaid eligibility determinations for most SSI recipients. Only DHH makes Medicaid ineligibility determinations for SSI claimants/recipients.
DHH makes both eligibility and ineligibility determinations in all other Medicaid categories. Some of these Medicaid categories are listed in SI 01715.005 (Medicaid Groups) and SI 01715.015 (Special Group of Former SSI Recipients). Individuals who inquire or appear to be eligible for these Medicaid programs may be referred to the local DHH/BHSF Medicaid office.
The information below provides specifics for some of these programs in Louisiana:
1. Title II COLA
Included in the list in SI 01715.015 are SSI recipients who would continue to receive SSI payments but for a title II COLA (Section 503 of P.L. 94-566 and Lynch v. Rank court case). Annually, at COLA time, Louisiana DHH receives two tapes identifying this protected group:
The 503 leads (Pickle) file identifies SSI recipients who will no longer receive an SSI payment once the title II COLA is received. DHH automatically converts these cases as Louisiana Pickle cases and continues Medicaid coverage under a State program. No separate Medicaid application with DHH is required for conversion.
The Lynch v. Rank file identifies individuals who would have been identified at COLA time except that they were ineligible for SSI (e.g., N04, M01/M02 with $0 payment) when the Lynch file was run, but could be eligible now except for the title II COLA increase. The Lynch v. Rank file provides information for the current year plus the two preceding years. The file is usually transmitted to States in mid-December. A Medicaid application must be file with DHH by individuals in this category.
If an individual meets this Medicaid extension provision (i.e., would have been eligible for SSI except for the COLA increase) and alleges after the beginning of the new year that there has been no contact from DHH, refer the individual to DHH using Exhibit 2. Photocopy Exhibit 2 as needed. Completion of Exhibit 2 is self-explanatory.
Exhibit 2 can also be used to refer inquiries from individuals who may be eligible under the Pickle provision.
2. Disabled Adult Children and Widower(er)s
Although DHH is notified via the SDX when these SSI recipients lose SSI, there are times when SSA receives inquiries from the former SSI recipients. To ensure that these former SSI recipients are timely identified by DHH, refer these inquirers to the State DHH office using Exhibit 2.
N. Enrollment Centers
Louisiana DHH is contracting with local agencies to enroll individuals in the Medicaid program. These local agencies are called Enrollment Centers (ECs). ECs are government or private entities who will only complete a Medicaid application for individuals who do not qualify for a cash assistance program (e.g., AFDC, SSI, etc.). DHH will continue to administer the Medicaid program.
ECs will forward the Medicaid applications and any available documents to the local BHSF Medicaid caseworker. However, ECs should not be requesting benefit or entitlement information from SSA.
The contracting of ECs is an ongoing process and ECs may discontinue their association with DHH at any time. FOs should continue a close working relationship with local Medicaid offices to maintain a current referral list of ECs in their service area.
O. Medicaid Coverage in the Month of Move
When an SSI recipient moves from another State with intent to reside in Louisiana, Medicaid eligibility resulting from SSI payment or Section 1619(b) is effective the month after the month of move to Louisiana (SI 01410.030F.)
Louisiana DHH Certification for Medicaid Eligibility
TO: Louisiana Department of Health & Hospital Date: _________
______________________________ Attn: ____________________
______________________________ (Always complete for
__________________, LA _______ Emergency Certification)
I.This individual was eligible for SSI and Medicaid. SSA is unable to establish a record or to provide complete information on the SDX. Please issue a Medicaid card for the period of eligibility indicated below.
Reason: (check one) __Systems Limitation __Emergency
__Closed Period of Eligibility Certification
Type of Recipient: (circle one) AI AS BI BS BC DI DS DC
Name of Recipient: _____________________________________
Mailing Address _____________________________________
Including Representative _____________________________________
Payee & Zip Code: _____________________________________
Social Security Number: ______________________ Sex: ____
Date of Birth: ______________ Mo/Day/Year of SSI Application: __________
TPL Code: ______________ Transfer of Resources (yes or no): ____
First Month/Year of SSI Payment in Louisiana: ______________
If closed period of eligibility, show all months of eligibility: ______________
If the individual is not currently eligible for SSI, give reason for suspension or termination and the effective date of non-pay: ________________________________________
II. SSA previously submitted a manual Medicaid certification for the above named individual and SSN. This individual is no longer eligible for SSI effective: ______. Reason: ___________________________________________.
III. FROM: Social Security Administration _______________________
______________________________ (CR Signature)
______________________________ (Phone #) _______________
Emerg. Cert. Auth.-OS/MSS or above
TITLE II COLA/DAC/WIDOW(ER) MEDICAID EXTENSION REFERRAL LETTER
TO: Louisiana Department of Health & Hospital Date: _________
__________________, LA _______
(check 1. Or 2.)
_____1.The following individual was eligible for Supplemental Security Income in ______, 20__ *, but became ineligible effective with ______, 20__ * because of a title II cost-of-living adjustment (COLA) increase paid to the eligible person or his/her spouse or due to __________________.This person may now be a candidate for preservation of Medicaid eligibility under the provision of:
_____ Section 503 of Public Law 94-566, or
_____ Lynch v. Rank court decree.
_____2. The following individual was eligible for SSI in __________,____ but became ineligible in _____________,_____ because of entitlement to or an increase in
_____ DAC, or
_____ widow(er) benefits.
Name and Address ______________________________
Parish of Residence ______________________________
Social Security Number ____________________________
Title II Claim Number ______________________________
Gross Title II Payment Prior to COLA _______________
Current Gross Title II Payment _______________
Other Current Month Income (If any) _______________
*If there is a break in entitlement between these two dates, show the months of ineligibility and payment status code for each month: ___________________________________________________________
From: Social Security Administration ______________________________
______________________________ Area Code/Telephone
Print Name of SSA Employee