Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Endnotes: Citations, Additional Information, and Web Addresses


  1. Letty Carpenter is the original author of this chapter. Ernest McKenney and Janet O’Keeffe updated the chapter.

  2. This Primer uses person-first language when referring to persons with disabilities and elderly persons, unless referring to the specific language used in statutes, regulations, or programs, as in this instance.

  3. Additional information about the Medicare program can be obtained from the CMS website at http://www.cms.gov/home/medicare.asp.

  4. The amount of monthly earnings considered as SGA depends on the nature of a person’s disability. The Social Security Act specifies a higher SGA amount for statutorily blind individuals ($1,640 per month in 2010); Federal regulations specify a lower SGA amount for non-blind individuals ($1,000 per month in 2010). Both SGA amounts generally increase with increases in the national average wage index. Additional information is available at http://www.ssa.gov/OACT/COLA/sga.html.

  5. State Medicaid Director Letter, April 9, 2010 at http://www.cms.gov/smdl/downloads/SMD10005.PDF.

  6. Subclauses (I)–(VII) of §1902(a)(10)(A)(i) of the Social Security Act.

  7. As amended by §2001(c) of the Affordable Care Act.

  8. Benchmark rules apply to the new group whether or not the state has otherwise elected the option to provide benchmark benefit coverage under its State Plan. Individuals in the new group who are exempt from mandatory enrollment in a benchmark benefit plan must receive medical assistance under the state’s currently approved plan. Others must be provided with benchmark or benchmark-equivalent coverage, including Secretary-approved benchmark coverage described in §1937(b)(1)(D). Consistent with the provisions of §1937, children covered under the new group must receive all Early and Periodic Screening, Diagnostic, and Treatment services.

  9. If individuals have only work earnings (i.e., they do not have any unearned income), and they do not pay for any work expenses, they can earn up to $1,433 per month in 2010 before their SSI federal cash payments stop. Additional information is available at http://ssa-custhelp.ssa.gov/cgi-bin/ssa.cfg/php/enduser/std_alp.php?p_sid= n6qe7NWj.

  10. See Endnote 4.

  11. Section 1902(r)(2) of the Social Security Act.

  12. This limitation applies only to income and only to certain optional eligibility groups. There are no such limits on using §1902(r)(2) to liberalize rules for resources.

  13. Under §1902(r)(2) of the Social Security Act, a state can elect to disregard more generous amounts. Note: For the first time since the poverty guidelines began to be issued in 1965, the annual average Consumer Price Index has decreased from the figure for the previous year. Therefore, the Department of Health and Human Services poverty guidelines have been frozen until at least May 31, 2010 at 2009 levels in order to prevent a reduction in eligibility for certain means-tested programs, including Medicaid, Supplemental Nutrition Assistance Program, and child nutrition. Additional information is available at http://aspe.hhs.gov/poverty/09extension.shtml.

  14. This provision applies to §209(b) states as well, which cannot use more restrictive eligibility criteria for this group.

  15. States can use higher levels or additional disregards under the §1902(r)(2) exception.

  16. Typically this is every month. In some states it is every 6 months. But in the latter case, the person must be able to spend down an amount that equals six times their monthly “excess” income before becoming eligible.

  17. State-by-state information concerning supplements for SSI beneficiaries may be found in State Assistance Programs for SSI Recipients, January 2009. (Released October 2009). Social Security Administration, Office of Policy, Office of Research, Evaluation, and Statistics. Available from Social Security Online at http://www.ssa.gov/policy/docs/progdesc/ssi_st_asst/2009/.

  18. Under §1902(r)(2), described above.

  19. Whether or not the income is counted depends on the specific nature of the transaction; for example, who the payment goes to and what the funds are used to purchase, as determined by additional Medicaid rules.

  20. A recent state survey found that of 43 states (7 did not respond), 19 allow Miller Trusts for institutionalized individuals. Of the 7 states that did not respond, based on 2000 data, 1 allows Miller Trusts; this adds up to 20 states. For states that use the 300 percent rule for HCBS waivers, of the 43 states that responded, 18 allow Miller Trusts. Of the 7 states that did not respond, based on 2000 data, 1 allows Miller Trusts, this adds up to 19 states. Lina Walker, AARP Public Policy Institute. Personal communication, March 24, 2010.

  21. Post-eligibility rules apply to all individuals in institutions, regardless of their eligibility group.

  22. Post-eligibility share-of-cost rules also apply to persons in ICFs/ID, long-term hospitals, and other medical institutions, regardless of eligibility category. Persons who become eligible by meeting a medically needy spend-down obligation also face an additional post-eligibility share-of-cost obligation based on their remaining income.

  23. This description is condensed from the analysis provided by Coffey, G. (January 2010). The Medicaid Long-Term Services and Supports Provisions in the Senate’s Patient Protection and Affordable Care Act.

  24. In 1990, the Supreme Court ruled in Sullivan vs. Zebley, that in order to meet the standard of equal treatment, the initial disability determination process for children must include a functional limitation component just as it is used for adults. The decision in the case that successfully contested the 1996 definitional change became moot in 1997, when §4913 of the Balanced Budget Act of 1996 (P.L. 105-33) restored Medicaid to the children who had lost eligibility under SSI’s 1996 definitional change. See http://www.dhs.state.or.us/spd/tools/crew/blitz/protected/Protected-HO.pdf.

  25. States may also use more liberal rules, such as not counting the parents’ income and resources under §1902(r)(2).

  26. This differential treatment comes about because SSI treats persons living in an institution as a separate household and eligibility unit than their family members. The §209(b) states are exceptions in that they continue to deem, even for persons who live in institutions.

  27. The Tax Equity and Fiscal Responsibility Act of 1982, P.L. No. 97-248, 96 Stat. 324 (September 3, 1982).

  28. Section 1619 and, equivalently, §1905(q) of the Social Security Act.

  29. The amount of the SSI benefit is decreased as earnings increase over the allowable amount. The Social Security Administration has published a rule to adjust the SGA level automatically each year for individuals with impairments other than blindness. The adjustment is based on any increase in the national average wage index. See http://www.ssa.gov/OACT/COLA/sgadet.html.

  30. Section 1619(b).

  31. Numbers from “Quarterly Report on SSI Disabled Workers and Work Incentive Provisions” (September 1999), Social Security Administration, Office of Research, Evaluation, and Statistics.

  32. Numbers from “SSI Disabled Recipients Who Work, 2008,” available from Social Security Online at http://www.ssa.gov/policy/docs/statcomps/ssi_asr/2008/sect07.html#table44.

  33. The 1997 provision is in §4733 of the Balanced Budget Act of 1997 (P.L. 105-33). The 1999 provision is in §201 of the Ticket to Work and Work Incentives Improvement Act of 1999 (P.L. 106-170).

  34. States are not permitted to use §1902(r)(2), described above, as a way to get to a higher effective income level at which full premiums are charged.

  35. This includes §209(b) states.

  36. The penalty for resource transfers in SSI, enacted in P.L. 106-169, is a loss of SSI benefits for a period of time. If the Social Security Administration finds that resources were transferred for less than fair market value in the 36 months prior to application, then a penalty period begins in the month the transfer occurred. The duration in months is calculated by dividing the amount transferred by the maximum monthly cash benefit otherwise payable.

  37. The period is 60 months if assets were transferred into or out of certain trusts.

  38. Social Security Act, §1917(c)(2)(iii) and (iv).

  39. Unused assets in the trust must revert to the state on the death of the individual, up to the total Medicaid amount spent on the individual’s behalf.

  40. The penalty does not apply to individuals who are eligible for HCBS waiver programs under community financial eligibility rules.

  41. The look-back period begins on the date someone applies for Medicaid. The penalty period begins on the date the person becomes eligible for Medicaid, not the date of application. In many instances they are the same date.

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