210 R.I. Code R. 210-RICR-40-15-1.4

Current through December 3, 2024

Section 210-RICR-40-15-1.4 - SSI-Eligible Beneficiaries

A. Rhode Island provides Medicaid coverage to anyone who is eligible for and receiving SSI, based on a determination by the Federal SSA. The State automatically enrolls SSI beneficiaries in Medicaid upon receipt of electronic notification from the SSA and must continue to provide coverage unless or until SSI status changes. The SSA also determines whether working adults with disabilities receiving SSI qualify for continuing Medicaid eligibility under two (2) special provisions in §§1619(a) or (b) of Title XVI, the Federal law establishing the SSI program.

B. Under §§1619(a) and (b) of Title XVI, SSI beneficiaries who have increased earned income from work are able to retain their Medicaid coverage. The amount of the additional earned income affects whether §§1619(a) or (b) provisions apply and, respectively, whether SSI cash assistance is reduced or eliminated. However, Medicaid primary care essential benefit coverage and, as applicable, LTSS continue without regard to changes in SSI status until the State is notified otherwise by the SSA.

1. 1619(a) - "Special cash assistance" is available when an SSI beneficiary with a disability has gross earned income for the month that exceeds the amount ordinarily allowed to obtain or retain SSI eligibility. Both the special cash payments and Medicaid coverage are authorized in this instance under §1619(a) . Any beneficiary may qualify for 1619(a) as early as his or her second (2^nd) month on the SSI rolls. To qualify, a person must:

a. Continue to have a disabling impairment and meet all other non-disability requirements.

b. Have been eligible for and received a regular SSI cash payment based on disability for a previous month within the current period of eligibility. The prerequisite month does not necessarily have to be the immediate prior month.

2. 1619(b) - SSI beneficiaries who have earnings too high for an SSI cash payment may be eligible for Medicaid if they meet certain requirements. To qualify for continuing Medicaid coverage under §1619(b), a person must:

a. Have been eligible for an SSI cash payment for at least one (1) month before the month when §1619(b) is established;

b. Continue to have a disabling impairment and, except for earnings, meet all other non-disability requirements;

c. Need Medicaid benefits to continue to work; and

d. Have gross earnings after excluding all work-related impairment expenses, blind work expenses, and earnings used to achieve an approved plan for self-support that are insufficient to replace SSI, Medicaid, and publicly funded attendant care services.

(1) SSA uses a threshold amount to measure whether a person's earnings are high enough to replace his/her SSI and Medicaid benefits. This threshold is based on the: amount of earnings which would cause SSI cash payments to stop in the person's State and average Medicaid expenses for persons who are blind or living with a disability in the State. The amount is recalculated annually and is available on the SSI program operations page titled: "SI 02302.200 Charted Threshold Amounts" and is available at: https://secure.ssa.gov/poms.nsf/lnx/0502302200

(2) If a SSI beneficiary has gross earnings higher than the threshold amount, SSA calculates an individual threshold amount, taking into account:

(AA) Impairment-related work expenses;

(BB) Blind work expenses;

(CC) A plan to achieve self-support; or

(DD) The value of any personal attendant services that are publicly funded through the DHS Office of Rehabilitative Services; and

(EE) Medical expenses above the average State amount or, if higher, the person's actual medical expenses.

C. The respective roles and responsibilities of the State and beneficiaries eligible for continuing Medicaid coverage through §§1619(a) or (b) are as follows:

1. State

a. Benefits. The State must ensure that all required primary care essential benefits and any necessary work supports covered under the Medicaid State Plan or Section 1115 demonstration waiver are available to members of this coverage group on a timely basis.

b. Continuing eligibility. All SSI Medicaid-eligible beneficiaries are auto-renewed unless or until the State receives notification of termination of SSI. The State must evaluate whether Medicaid eligibility is available in all other coverage categories before initiating the termination process in accordance with §00-2.6.3(A) (3) of this Chapter.

2. Applicants/Beneficiaries

a. Applicants and beneficiaries must provide timely, accurate and complete information about any eligibility factors subject to change, including any changes in work circumstances or earnings that may affect continuing access to coverage through the pathways identified in this Part. In addition:

(1) Consent - At the time a Medicaid beneficiary eligible on the basis of SSI no longer qualifies for continuing coverage under §1619(a) or (b), the State may request that he or she provide the State with consent to retrieve and review any information not currently on record pertaining to the eligibility factors subject to change through electronic data matches conducted through the State's eligibility system. Once such consent is provided, the Medicaid agency may retrieve and review such information when conducting all subsequent eligibility determinations and annual renewals.

(2) Duty to Report - Medicaid beneficiaries are required to report changes in eligibility factors to the Medicaid agency within ten (10) days from the date the change takes effect. Self-reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Flexibility in reporting is allowed when a beneficiary changes work status and employers do not provide timely documentation of such changes.

210 R.I. Code R. 210-RICR-40-15-1.4

Amended effective 10/5/2021