Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Endnotes

01/24/2005

  1. This chapter is based in large part on the especially clear description of Medicaid eligibility authored by Letty Carpenter in Chapter 2 (“Financial Eligibility Rules and Options”) in Gary Smith, Janet O’Keeffe, Letty Carpenter, Pamela Doty, Gavin Kennedy, Brian Burwell, Roberta Mollica, and Loretta Williams (2000). Understanding Medicaid Home and Community Services: A Primer. George Washington University, Center for Healthy Policy Research. Available at http://aspe.hhs.gov/daltcp/reports/primer.htm (accessed February 22, 2005).

  2. Based on: Andy Schneider, Risa Elias, and Rachel Garfield (2002). "Chapter 1: Medicaid Eligibility" in: Schneider, A., Elisa, R., Garfield, R., et al. (2002). The Medicaid Resource Book. Menlo Park CA: The Kaiser Commission on Medicaid and the Uninsured.

  3. Legal immigrants who entered the U.S. before August 22, 1996 must also meet the definition of a "qualified immigrant" in order t be eligible for Medicaid. A qualified immigrant is one whose category of immigration status is (a) Legal Permanent Resident (LPR), (b) Refugee, (c) Asylee, or one of several other categories. Immigrants deemed "nonqualified" are not eligible for basic Medicaid services regardless of legal status. Non-qualified immigrants are either (a) a Person Residing Under Color of Law (PRUCOL), (b) undocumented or (c) a non-immigrant such as a student or foreign visitor. For more detailed information, please see the National Health Law Program paper Immigrant Access to Health Benefits: A Resource Manual, available at www.accessproject.org/downloads/Immigrant_Access.pdf

  4. In particular, please see the following: (a) United States Government Accounting Office (2002). Welfare Reform: Outcomes for TANF Recipients with Impairments. (GAO-02-884); (b) National Council on Disability (2003). TANF and Disability -- Importance of Supports for Families with Disabilities in Welfare Reform; (c) Office of Inspector General, U.S. Department of Health and Human Services (2002). State Strategies for Working with Hard-to-Employ TANF Recipients. (OEII-02-00-00630); and, (d) Eileen P. Sweeney (2000). Recent Studies Indicate that Many Parents Who are Current or Former Welfare Recipients have Disabilities or Other Medical Conditions. Washington DC: Center on Budget and Policy Priorities. Some studies have found that the incidence of mental impairments among adults in TANF households ranges from 30 to 40 percent.

  5. Federal law concerning the Supplemental Security Income program is in Title XVI of the Social Security Act.

  6. The “Adult Listings” are contained in the Social Security Administration’s publication Disability Evaluation Under Social Security (also known as the Blue Book). The publication is available at ssa.gov/disability/professionals/bluebook. Mental disorders include mental retardation, organic brain disorders and mental illnesses, among others.

  7. The Diagnostic and Statistical Manual (DSM) is updated periodically. The Listings of Mental Impairments parallels the DSM-III, which was used in the mid-1980’s. The current version used by mental health professionals is the DSM-IV.

  8. Children (individuals under age 18) are not subject to the substantial gainful activity test. Instead, they are evaluated on the basis of whether their impairment(s) result in “marked and severe functional limitations.”

  9. From 1982 through June 1999, the SGA standard remained unchanged at $500 per month. In July 1999, the standard was increased to $700 per month and indexed to the year-over-year change in the national average worker wage index. The SGA standard also applies to SSDI beneficiaries.

  10. Federal law concerning the Social Security Disability Insurance program is in Title II of the Social Security Act.

  11. Social Security Administration (2002). Annual Statistical Supplement. Table 7.F2.

  12. Social Security Administration (2002). Annual Statistical Supplement. Table 3.C61.

  13. Information here and elsewhere in this chapter about state policies concerning Medicaid eligibility for adults with disabilities, is generally based on information compiled by the National Association of State Medicaid Directors (NASMD) and available at nasmd.org/eligibility/. The NASMD information was compiled in 2001 but is updated periodically.

  14. §1634 of the Social Security Act permits the Social Security Administration to enter into an agreement with a state for this purpose.

  15. Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon and Utah

  16. Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia.

  17. SSI payment amounts are adjusted annually in January based on changes in the consumer price index.

  18. Unlike the FBR and SGA limits, the SSI resource limit is not indexed and has remained unchanged for many years.

  19. Section 209(b) refers to the section of the Social Security Act Amendments of 1972 that gave states this option. This provision is contained in §1902(f) of the Social Security Act.

  20. For example, SSI is based on whether a person’s disability will cause substantial impairment for at least 12 months. In Indiana and New Hampshire, the expected duration of the impairment must be at least 48 months.

  21. See also: CMS/CMSO/Disabled and Elderly Health Programs Group (June 2002). “Groups Deemed to be Receiving SSI for Medicaid Purposes.” See also: Robert Bohlman, National Alliance for the Mentally Ill -- “Switch from SSI to SSDI Does Not Mean Loss of Medicaid” at nami.org/Content/ContentGroups/Enews/1996/December_1996/Switch_From_SSI_To_SSDI_Does_Not_Mean_Loss_Of_Medicaid.htm

    There are three eligibility groups for whom Medicaid must continue after SSI is lost: (a) People who lost SSI when they received automatic cost-of-living adjustments (COLAs) in Social Security (sometimes nicknamed “Pickle people” after Congressman Pickle, one of the sponsors of the original COLA legislation); (b) “Adult children with disabilities” who lose SSI when they become entitled to Social Security benefits based on a parent’s Social Security entitlement. “Adult children with disabilities” are individuals who have a disability before age 22.

    When such a person’s parent becomes disabled, retires or dies, the individual becomes eligible for SSDI. If an individual had an SSI benefit, then the SSDI benefit -- if sufficiently large -- completely replaces SSI. Federal law requires that these individuals continue to be considered SSI beneficiaries and receive Medicaid coverage; and, (c) Individuals ages 60-64 who lose SSI due to receipt of Social Security benefits for widows and widowers with disabilities.

  22. The Employment Opportunities for Disabled Americans Act of 1986 (P.L. 99-643).

  23. In January 2004, the Social Security Administration published proposed rules concerning the treatment of assets in determining SSI eligibility. These proposed rules would (a) exclude household goods and personal effects from countable resources and (b) remove the dollar value limit on a person’s personal vehicle. Federal Register, Vol. 69, No. 3, pp. 554-558 (January 6, 2004).

  24. Also in the Employment Opportunities for Disabled Americans Act of 1986. The enactment of these provisions followed demonstrations that began in 1980. In 1982, these options moved to full implementation nationwide. However, it was not until 1986 that these provisions were made permanent.

  25. Center for Workers with Disabilities (2002). Work Incentives Development Report Series: Section 1619(b) Operational Challenges and Selected State Remedies. Washington DC: National Association of State Medicaid Directors. This series of reports contains extensive information concerning Section 1619(b) eligibility and some of the problems encountered in its implementation. The series is available at nasmd.org/disabilities/pubs/special.asp

  26. Social Security Administration. 2002 SSI Annual Report.

  27. More detailed information concerning the latitude afforded states under §1902(r)(2) may be found in the following publications: (a) Center for Workers with Disabilities (2002). Building Work Incentives Using Section 1902(r)(2) of the Medicaid Statute. Washington, DC: National Association of State Medicaid Directors, available at nasmd.org/disabilities/pubs/special2.pdf; and, (b) CMS (2001) Medicaid Eligibility Groups and Less Restrictive Methods of Determining Countable Income and Resources: Questions and Answers. Available at cms.hhs.gov/medicaid/eligibility/elig0501.pdf

  28. Federal Register, January 11, 2001, pps. 216-2322. These rules are located at 42 CFR Part 435.

  29. The Federal Poverty Level is higher in Alaska and Hawaii. ($11,210 and $10,330, respectively, in 2004 for one person).

  30. California, District of Columbia, Florida, Hawaii, Illinois, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nebraska, New Jersey, North Carolina, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Utah and Virginia.

  31. For more information on the medically needy option, including the states that offer this option and the characteristics of their programs, please see: Jeff Crowley (2003). Medically Needy Programs: An Important Source of Medicaid Coverage. Washington DC: Kaiser Commission on Medicaid and the Uninsured, available at kff.org/medicaid/4096-index.cfm

  32. For example, Louisiana has excluded mental health services as well as others; some states do not include prescribed drugs.

  33. A 209(b) state may elect to use a different income or resource standard for the aged, blind and disabled than the standard that is used for AFDC-related individuals.

  34. Typically this is every month. In some states, it is every six 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.

  35. A person’s share of cost obligation is reduced when the person has a spouse or other dependents.

  36. States at their option may disregard a certain amount of income for waiver beneficiaries to support themselves and any dependents in the community. This amount is typically called a personal maintenance allowance. The amount of income remaining after subtracting the personal maintenance allowance and the allowance for dependents is the cost-sharing obligation. States vary in the amount of the maintenance allowance they allow, from $800 to $1,737 (the full 300 percent of SSI standard).

  37. There is extensive information concerning these options at the CMS web site cms.hhs.gov/twwiia/default.asp. There also are considerable resources available on the Center for Workers with Disabilities web site: nasmd.org/disabilities/about/altdefault.asp

  38. More information concerning state initiatives to promote employment for people with disabilities through Medicaid buy-in options and other strategies is available from the National Association of State Medicaid Directors Center for Workers with Disabilities at nasmd.org/disabilities/taskforces/altdefault.asp

  39. More information concerning these grants is located at cms.hhs.gov/twwiia/infrastra.asp

  40. Jean P. Hall and Michael H. Fox (2002). Working Healthy -- A Medicaid Buy-In for Kansas. Univesrity of Kansas Department of Health Policy and Management.

  41. Jean P. Hall and Michael H. Fox (2003). Early Enrollment in Working Healthy: Program Features Make A Difference. Univesrity of Kansas Department of Health Policy and Management.

  42. P.L. 106-170.

  43. For a table comparing the features of BBA and TWWIIA (Basic and Medical Improvement), please see: cms.hhs.gov/twwiia/comchart.asp

  44. Periodic continuing disability reviews assess whether individuals still meet SSI/SSDI eligibility criteria.

  45. SSDI beneficiaries whose earnings exceed the SGA standard enter what is termed a Trial Work Period. Once that Trial Work Period is completed and the person’s earnings continue to exceed the SGA standard, the person faces the potential termination of SSDI. SSDI does not have a provision similar to 1619(a) that benefits SSI beneficiaries.

  46. Contained in §1931 of the Social Security Act.

  47. In particular, please see the following: (a) United States Government Accounting Office (2002). Welfare Reform: Outcomes for TANF Recipients with Impairments. (GAO-02-884); (b) National Council on Disability (2003). TANF and Disability -- Importance of Supports for Families with Disabilities in Welfare Reform; (c) Office of Inspector General, U.S. Department of Health and Human Services (2002). State Strategies for Working with Hard-to-Employ TANF Recipients. (OEII-02-00-00630); and, (d) Eileen P. Sweeney (2000). Recent Studies Indicate that Many Parents Who are Current or Former Welfare Recipients have Disabilities or Other Medical Conditions. Washington DC: Center on Budget and Policy Priorities. Some studies have found that the incidence of mental impairments among adults in TANF households ranges from 30 to 40 percent.

  48. Dee Mukherjee, National Association for the Mentally Ill. “New Law Denies SSI, SSDI to Those with Alcoholism and Drug Addictions

  49. A complete discussion of the effects of incarceration on SSI, SSDI and Medicaid benefits is found in the following publication: Bazelon Center for Mental Health Law. Finding the Key to Successful Transition from Jail to the Community -- An Explanation of Federal Medicaid and Disability Program Rules. Washington, DC.

  50. More information on the interplay between SSI, Medicaid, and incarceration can be found in the Bazelon Center for Mental Health Law publication, Arrested? What Happens to Your Benefits If You Go to Jail or Prison?, (2004). Washington, DC. Available at bazelon.org/issues/criminalization/publications/arrested/index.html

  51. As an example, in November 2004 Utah allowed inmates to re-apply for Medicaid six weeks before their anticipated release date in order to facilitate a smooth transition into Medicaid services. In addition, Utah provides presumptive Medicaid eligibility to inmates who normally must wait until a 90-day disability evaluation is completed, if they were deemed disabled prior to being incarcerated. This covers a large number of individuals with serious mental illnesses.

  52. Individuals in this age cohort are affected by the IMD exclusion, as discussed in Chapter 4.


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