TN 10 (06-96)

SI 01730.010 Determinations of Medicaid Eligibility

A. Policy — Period of Medicaid Eligibility

1. General

In section 1634 States, SSA determines whether an individual is eligible for Medicaid beginning with the day he/she becomes eligible for SSI payments or federally administered SSP's. (States determine retroactive Medicaid coverage, where applicable, as described in SI 01730.010A.3.) Medicaid eligibility continues for the same period for which the individual remains eligible for these payments (or 1619(b)). This can be the first day of the month or, if proration applies, the same day the individual meets all eligibility criteria for SSI/SSP payments and Medicaid. This same rule applies when an individual reestablishes eligibility for SSI or SSP's after a month(s) of ineligibility. (See

SI 02302.010B. ff. for an explanation of special recipient status under section 1619(b).)

2. Individual Entitled to a Mandatory SSP

Since mandatory SSP's are not prorated, persons eligible for these payments in a month are also eligible for Medicaid beginning with the first day of the month. This is the case even if proration applies to the SSI payment the individual receives, and/or the individual actually receives a prorated optional SSP in the month because the prorated optional SSP is higher than the mandatory SSP.

3. Retroactive Medicaid Eligibility

A State may establish Medicaid eligibility for the recipient as early as the first day of the third month preceding the month an application for SSI payments or SSP's is effectively filed if the individual would have met the eligibility criteria during this time. The three calendar months can be in addition to any days subject to proration. (See SI 02005.007.)

4. Special SSI Status and Medicaid Eligibility

Certain individuals eligible for special SSI recipient status are eligible for Medicaid although no cash SSI payments are due. Included in this group are certain 1619(b) individuals, those who would be eligible for title XVI but for a title II cost-of-living increase, certain disabled adult children, certain widow(er)s, and certain drug addicts and alcoholics not receiving payment. (See SI 01715.015 for further explanation.)

B. Policy — Continuance of Medicaid Eligibility

The following discussion relates to section 1634 States.

1. General

When Medicaid eligibility is established, it continues until the earliest of the following:

  • The recipient becomes ineligible to receive an SSI payment, a federally administered SSP, or leaves 1619(b) status and does not meet another coverage provision under the State Medicaid plan in effect; or,

  • The recipient refuses assignment of rights in certain States; or,

  • The recipient refuses to provide TPL information; or

  • The eligible person no longer resides in the State where Medicaid eligibility has been established. However, note that a new determination of eligibility may apply with respect to the new State of residence (depending on the Federal/State agreement in effect). (See SI 01410.000 ff.); or,

  • The State plan approved under title XIX is no longer in effect or is amended.

2. Ineligible for SSI Payments

SSA informs the State through the State data exchange (SDX) when a recipient is ineligible for an SSI payment. The SDX shows the reason for ineligibility (i.e., payment status code). The State is then in a position to take appropriate action with regard to Medicaid eligibility.

(See SI 01715.015 for a discussion of continued Medicaid coverage for certain individuals.)

3. Eligible Only For State Supplement

In section 1634 States all recipients of mandatory SSP's and SSA-administered optional SSP's are eligible for Medicaid coverage unless they refuse to assign their rights to any third party medical payments or refuse to provide TPL information. (See SI 01730.040 and SI 01730.045 for a more complete explanation.)

In States where SSA makes Medicaid determinations on behalf of the State and the State administers its own optional supplementation program, the State can elect to provide Medicaid coverage for recipients of optional SSP's.

In States where SSA does not make Medicaid determinations for the State, the State determines Medicaid eligibility for recipients of SSI and SSP's according to its Medicaid plan and coverage provisions.

4. Recipient Becomes Ineligible for Payment

When a recipient who has been eligible only for an SSA-administered SSP becomes ineligible for an SSP due to income and is not a 1619(b) participant, SSA cannot make Medicaid eligibility determinations since the individual is no longer within the scope of the section 1634 agreement with the State. The State is notified via the SDX that SSA can no longer make a Medicaid eligibility determination for the person and the reason for ineligibility (through the payment status code).

C. Reference

State and county of residence for SSP and Medicaid purposes, SI 01410.010.

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SI 01730.010 - Determinations of Medicaid Eligibility - 02/06/2013
Batch run: 02/06/2013