TN 33 (08-23)

GN 02610.044 Title II Offset Based on Title XVI Presumptive Disability Payments

A. Background

When there is a medical allowance for concurrent title II/title XVI disability claims and SSI presumptive disability (PD) payments have been made, the title II claim is often adjudicated before the final allowance is posted to the SSI claim. If a PD payment has been made for a month in the title II windfall offset period, a title II offset computation may be processed based on an MBR/SSR interface. This offset computation is correctly applied because all requirements for title II offset are met. When the final allowance is posted to the SSI claim, if the title II monthly benefit amounts are large enough, no additional SSI benefits would be payable for the retroactive months. If the SSI recipient were found ineligible for some months in the retroactive period they would lose potential Medicaid eligibility inappropriately.

Example: The SSI date of eligibility is 1/00, a PD decision is made in 2/00, and PD payments are made for 3/00 - 4/00. A final allowance results in a title II CMA of $600 being paid in 5/00 and retroactive benefits of $600 per month being withheld. The windfall period is 1/00 – 6/00. An automated title II offset computation processes before the SSI claim is finally adjudicated. Following the offset computation, the SSR shows:

1/00 - PS S21 (zero offset*)

2/00 - PS E02 (zero offset*)

3/00 - PS C01 ($512 SSI paid and $512 title II offset)

4/00 - PS C01 ($512 SSI paid and $512 title II offset)

5/00 - PS N01 (zero offset*)

6/00 - PS N01 (zero offset*)

*See SI 02006.010A.4 for definition of zero offset.

Final adjudication of the SSI claim results in the following on the SSR:

1/00 - PS E02

2/00 - PS C01 and nothing payable due to zero offset (CMPH FMA shows $512 payment, but WFA and WFO are 0 and there is no WFX in WCMP.)

3/00 - 4/00 PS C01 (SSI paid and title II offset applied)

5/00 – 6/00 PS N01 (due to payment of title II benefits)

B. Procedure

Use the following procedures to protect the Medicaid eligibility in the title XVI retroactive period. These procedures are similar to those that have been used in the Third Circuit and throughout the U.S. when title XVI offset is inappropriately applied (GN 02610.065 and SI 02006.205B.1.).

If the beneficiary is eligible in the retroactive months for title XVI without counting the title II income:

  1. 1. 

    Issue an A-OTP (see SM 01901.001 ff.) to make a payment of $1 for each month that the offset precluded payment of retroactive title XVI. In the example in item A above, an A-OTP would be made for 2/00.

  2. 2. 

    Input an N TAC for the overpayment caused by the A-OTP unless the system suspended collection of it. See SI 02260.030 for guidelines for the system process and tolerances. See SM 01311.280 for more instructions.

  3. 3. 

    Issue a manual notice of the title XVI payment for the closed period to the individual. The recipient can take this award notice to the appropriate Medicaid agency if needed to obtain Medicaid. See NL 00802.010, “Initial Award Notice—SSA-L8025, SSI Notice of Award,” for how to prepare the award notice.

If using the SSA Notices program (FONS/DPS) or a preprinted form (see NL 00802.015, “Completion of the SSA-L8025”), insert the following immediately after the payment chart which lists amounts due (see GN 02610.067 for model notice):

  • Caption 1915, “Information About Medicaid”—See NL 00802.015A.2.g.; and the following paragraph:

  • “Since you are not eligible now for SSI, you are also not eligible for Medicaid based on SSI. However, if you need help with medical bills, you may still be eligible for medical assistance. Also, you may be eligible for Medicaid for the months we paid you SSI. Contact (1) for information about your State's medical assistance programs and your eligibility for Medicaid. When you visit that Agency, please take this letter with you. It will help the people there answer your questions.”

(1) Enter the name of the State Medicaid agency.

NOTE: The above procedures apply in both 1634 and non-1634 states. The fact that the individual received SSI could be material to their Medicaid eligibility, including the three month period prior to the SSI application.

If the individual is ineligible for title XVI in the retroactive months for a reason other than receipt of title II income, and for which they have not been notified, issue an appropriate manual notice (See NL 00801.001B.1. for when we send a notice, NL 00802.020 for when to use a manual denial notice, and SI 04010.020 for notice of initial determination and defective notices).

NOTE: Follow the special notice procedures in NL 01001.010 if the notice will be sent to a claimant, beneficiary, or representative payee who alleges being blind or visually impaired.

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GN 02610.044 - Title II Offset Based on Title XVI Presumptive Disability Payments - 08/16/2023
Batch run: 08/16/2023