TN 24 (10-04)

SI 02302.030 Section 1619 Process and Procedures

A. Process - 1619(a) - Earnings Over SGA

1. General

Eligibility for cash benefits under 1619(a) is a result of gross earnings at or above the SGA level. The SSR is able to distinguish 1611 regular eligibility from 1619(a) eligibility based on transmitted earned income. FO processing is seldom required to develop 1619(a) eligibility.

2. Systems Processing

The SSR places an individual in section 1619(a) status in any month in which:

  • Gross earnings in that month are at or above the SGA level,

  • Countable income is less than the FBR, and

  • The prerequisite month requirement is met.

See SM 01305.992 for a detailed description of 1619(a) systems processing.

B. Process - 1619(b) - Medicaid While Working

1. General

  1. Eligibility for continued Medicaid under section 1619(b) results when an otherwise eligible working blind or disabled person has countable earned income which makes his or her total countable income exceed the applicable breakeven point (i.e., the individual is ineligible for a federally-administered payment) and the individual also meets the Medicaid Use and Threshold Tests. The SSR will process most actions. However, some manual development is necessary.

  2. The Medicaid Use Test (SI 02302.040) and Threshold Test (SI 02302.045) must be applied at each 1619(b) redetermination. See SI 02305.016 for information about section 1619 redeterminations.

2. Systems Processing

  1. The SSR determines if the prerequisite month requirement is met. (See SI 02302.010.)

  2. The SSR performs a test computation to determine if the individual would be eligible for a cash benefit for the current month if he/she did not have excess countable earned income. All appropriate exclusions are applied.

  3. The test computation uses the individual's own countable unearned income plus any countable deemed income.

  4. If 1619(b) eligibility is being considered for both members of a couple (both members are working), the earned income of both is dropped for the test computation. If only one member's status (only one working) is being considered, only that member's earned income is dropped.

    If otherwise eligible, a recipient who is subject to the $30 payment cap and whose countable income precludes any SSI payment may be eligible for section 1619(b) if his/her countable unearned income is less than the full FBR.

  5. If the test computation indicates that the person would be eligible for a cash benefit absent his/her earned income, the SSR places the person in 1619(b) eligibility status pending FO resolution of the Medicaid Use and Threshold Tests. (See SI 02302.040 and SI 02302.045 for instructions pertaining to these tests.)

See SM 01305.991 for additional information about systems processing of 1619(b) records.

NOTE: The redetermination profile code of “W” is the only systems control for development of the Medicaid Use and Threshold Tests. (See SI 02305.016 and SM 01501.025D.1.d.)

C. Procedure – 1619(a) and 1619(b)

1. Earned Income Development

Since 1619 eligibility is based on the amount of a person's earned income, verify earned income quarterly as described in SI 02302.060. Attempt to coordinate recipient contacts for earnings verification, redeterminations, and CDRs to the extent possible.

2. Prerequisite Month

Almost all individuals previously in pay or eligibility status will meet the prerequisite month requirement. However, there are post-eligibility situations where the system cannot determine if the prerequisite month has been met (zee SM 01305.991). In these situations, the system places the record in payment status S05.

  1. If the case is a Start Date record and the prerequisite month requirement was met on the prior terminated record, follow SM 01305.991B.2.a.

  2. If the prerequisite month requirement was not met on the prior terminated record, or this is not a Start Date record, follow SM 01305.991B.2.b. An SGA determination is required if work is at the SGA level. (See DI 13010.110 for information regarding return to work within 12 months after onset.)

  3. If the individual receives SSI based on age and otherwise meets all requirements for 1619(b) eligibility, a disability determination is required. See below.

3. 1619(a) State Supplement Computation

See SI 02302.010B.2. for a list of States that elect to supplement 1619(a) cases. Determine the appropriate optional supplementary payment code for a 1619(a) month in the same way as for a regular SSI month according to SI 01415.001 and regional instructions.

4. 1619(b) Medicaid Use and Threshold Tests

Determine if the recipient meets the Medicaid Use and Threshold Tests at each scheduled redetermination per SI 02302.040 and SI 02302.045.

5. Notices

The SSR will generate 1619 notices (SI 02302.310).  However, FOs must issue a manual Notice of Decision (SI 02302.310, situation #6) when a manual award notice is sent to a blind or disabled individual age 18 or over.

6. 1619(b) Determinations for Couples

When one member of a couple works, only that member is eligible for 1619(b). The other member is ineligible for payment due to deemed income, not his/her own income; therefore, that member is not eligible for 1619(b). When both members work and they are ineligible for payment due to a combination of earned income and deemed income, then each person is separately eligible for 1619(b). Perform the threshold calculation on each person's income. If one person's income is over the charted threshold, perform the individualized calculation on that person only.

7. 1619 (b) Disability Determinations for Aged Individuals

Effective May 1, 1991 individuals who are age 65 or over may qualify for section 1619(b) eligibility (Medicaid While Working) provided that they are also blind or disabled.

Aged individuals with current earned income who are suspended due to excess income will be notified of their potential eligibility under section 1619(b) and advised to contact the FO if they believe they qualify.

a. Establish Disability/Blindness

Follow the steps below whenever a working aged individual becomes (or will become) ineligible due to excess income:

Step

Action

1

Ask the individual if he/she is blind or disabled.

If No - Stop. The person cannot establish 1619(b) eligibility.

If Yes - Go to step 2

NOTE: If the SSR already reflects multi-category eligibility for the individual, a new medical decision is not necessary.  Go to step 2 below.

2

Determine if the alleged date of onset is at least one month before all other 1619(b) requirements are met (i.e., the prerequisite month).

If No - Stop. The person cannot establish 1619(b) eligibility.

If Yes - Go to step 3

3

Determine if the individual would be eligible for an SSI payment if the his/her earnings were not considered.

If No - Stop. The person cannot establish 1619(b) eligibility.

If Yes - Go to Step 4

4

Determine if the individual meets the Medicaid Use Test per SI 02302.040.

If No - Stop. The person cannot establish 1619(b) eligibility.

If Yes - Go to Step 5

5

Determine if the individual meets the Threshold Test per SI 02302.045 and SI 02302.050.

If No - Stop.  The person cannot establish 1619(b) eligibility.

If Yes - Go to Step 6

6

Complete the appropriate disability forms per DI 11055.015.

7

Request a medical determination from the Disability Determination Service (DDS) per DI 11055.035.

  • Enter “Aged Individual - 1619(b) eligibility determination” in the Remarks section of the SSA-831-U3.

  • Specify in Remarks the date of onset which the DDS must establish for the person to meet the prerequisite month requirement (i.e., a month prior to when the person meets all other 1619 (b) requirements).

b. Favorable Disability Decision

If the DDS determines that the individual was blind or disabled and the onset date meets the prerequisite month requirement, proceed as follows:

Step

Action

1

Terminate the record using T30 or T33 procedures in SM 01801.001.

2

Establish a Start Date record per SM 01005.020.

NOTE: The type of claim (SM 01005.010) must be shown as blind or disabled.  Use the multi-category field (SM 01005.330) to reflect multi-category eligibility as an aged/blind or aged/disabled individual.

3

Prepare and mail a notice per NL 00801.010 and NL 00802.010.

4

Notify the Medicaid agency of the individual's eligibility under section 1619(b) using locally-established procedures.

NOTE: After the Start Date record is established, the State will receive notification through the State Data Exchange.

c. Unfavorable Disability Decision

If the DDS determines that the individual was not blind or disabled as of the prerequisite month, the DDS will issue the appropriate notice.

Enter “CMDS” in the Case Characteristics (CG) field per SM 01301.820.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0502302030
SI 02302.030 - Section 1619 Process and Procedures - 01/23/2013
Batch run: 01/23/2013
Rev:01/23/2013