Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Medicaid for SSI Beneficiaries

10/29/2010

SSI is the Federally-administered program that ensures a nationally uniform income floor for persons who are elderly, blind, or have other disabilities. To be eligible, both income and assets must be low. Thirty-nine states and the District of Columbia provide Medicaid to all individuals in any month in which they receive an SSI payment. Of these, 33 do so automatically, based on a list of SSI beneficiaries compiled by the Federal Social Security Administration. The other 7 require SSI beneficiaries to file a separate application with the state for Medicaid benefits. The remaining 11 states follow what is known as the 209(b) exception option that allows them to provide Medicaid to SSI beneficiaries only if they meet the state’s eligibility criteria, which may be more restrictive than those for SSI. (The 209(b) option is discussed in more detail below.)

New Eligibility Group Established by the Affordable Care Act of 20105

Section (§)2001 of the Patient Protection and Affordable Care Act of 2010 (hereafter, Affordable Care Act) amended the Medicaid statute to create a new eligibility group that all states participating in Medicaid must cover as of January 2014. For the first time since the Medicaid program was established, states will receive Federal Medicaid payments to provide coverage for the lowest income adults in their states, without regard to disability, parental status, or most other categorical limitations, under their Medicaid State Plans.

For this new eligibility group, the Affordable Care Act raises the income eligibility threshold to 133 percent of the poverty line and eliminates the assets test. All rules applicable under the Medicaid program in general apply to this new eligibility group, including rules relating to cost sharing. States can phase in eligibility by income level, but if they do, they must cover individuals with lower incomes before covering those with higher incomes. Parents of children who could be covered under Medicaid but are not cannot be covered under this new group unless their children are also enrolled in Medicaid.

The new group fills in the gaps in existing Medicaid eligibility coverage by making eligible very low-income individuals who are not otherwise eligible under mandatory eligibility categories. Thus, the law describes the individuals eligible under the new group as those who are not

  • Age 65 or older,
  • Pregnant,
  • Entitled to or enrolled in benefits under Medicare Part A,
  • Enrolled under Medicare Part B,
  • Receiving SSI benefits, or
  • Described in any of the other mandatory groups in the statute.6

The medical assistance provided to an individual in the new eligibility group must consist of benchmark coverage described in §1937(b)(1) of the Affordable Care Act or benchmark-equivalent coverage described in §1937(b)(2)7 unless the individual is exempt from mandatory enrollment in a benchmark benefit plan.8

Certain states--depending on their income eligibility standards prior to the enactment of the Affordable Care Act--will receive enhanced Federal Financial Participation for services provided for newly eligible individuals: 100 percent in 2014, 2015, and 2016; 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent thereafter.

For more detailed information about this new eligibility group, see the State Medicaid Director Letter issued April 9, 2010 at http://www.cms.gov/smdl/downloads/SMD10005.PDF. The Centers for Medicare & Medicaid Services (CMS) will be issuing additional guidance on other provisions contained in §2001 of the Affordable Care Act at a later date.

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