Presumptive SSI and Extended MC

Presumptive SSI clients are able to receive zero SOC MC benefits for up to six months from the date Presumptive Disability is approved while the Social Security Administration (SSA) makes a formal disability determination.

When an SSI/SSP applicant is approved for Presumptive Disability and then denied (after a formal disability determination), and a timely appeal is requested, SSI-based MC MUST be extended throughout the entire Social Security Administration appeal process.

A presumptive SSI client who is found NOT to be disabled during the formal disability determination process is terminated on MEDS with a denial code, instead of a discontinuance code (N07 Cessation of Disability).

When a denial code is used, MEDS cannot automatically identify and track these individuals for extended zero SOC MC eligibility, as it does for N07 individuals.

Identification of Presumptive SSI Individuals

Presumptive SSI clients are identified by the following information on MEDS:

MEDS Screens for SSI Individuals

Screen	Field	Description
INQM	AID-CODE	Aid code “60” will appear (with a time period of one to six months.)
INQX	DISABL-PAYMENT-CD	A letter “P” will appear if the client was approved for Presumptive Disability by Social Security Administration.
INQP	APPEAL-LEVEL	Should show a recent denial date and the denial reason. The appeal date for these clients should be a date that is after the date of the denial. Example: If there is a denial code of “N32” and a denial date of 08/02/07, then if the client had requested an appeal with Social Security Administration, the appeal date should usually be within 65 days of the denial date.

Referrals to the DHCS

Individuals meeting the criteria listed below must be referred to the DHCS for potential extended zero SOC MC eligibility:

• Self-identified individuals as a presumptive SSI client who was found NOT to be disabled during the formal disability determination, OR
• A MC applicant whose MEDS record indicates a short period of SSI eligibility (six months or less) AND an SSI denial code (not a discontinuance code).

The following actions occur when an individual meeting the criteria listed above is referred to DHCS:

1. EW:    
   1. Refers the client (name and SSN) to the district office MC Liaison, noting “Presumptive Disability approval/denial, appeal pending with Social Security Administration.”
2. MC Liaison:    
   1. Forwards the information to the MC Program Coordinator.
3. MC Program Coordinator:    
   1. Forwards the information to DHCS by contacting the MC Disability Unit.
4. DHCS:
   1. Confirms with SSA that:
      1. The individual received presumptive SSI, and
      2. The individual was found NOT to be disabled in the formal disability determination process.
      3. The disability determination is not yet “final.” 
   2. If the information is:
      1. Confirmed
         1. Activates extended zero SOC MC, and
         2. Tracks the client’s SSA appeal status on MEDS until the disability decision becomes “final.”    
      2. Not confirmed
         1. Does not activate extended zero SOC MC or track the appeal status.    
   3. Informs the MC Program Coordinator of the action taken.
5. MC Program Coordinator:    
   1. Forwards the information from DHCS to the MC Liaison.
6. MC Liaison:    
   1. Forwards DHCS information to the EW.
7. EW:    
   1. Takes the appropriate action to approve/deny MC. If DHCS:
      1. Activates the extended zero SOC MC
         1. Denies MC.    
      2. Does not activate extended zero SOC MC
         1. Processes the application to determine MC eligibility.
         2. Approves/denies as appropriate.    

Reminder: Social Security Administration disability decisions are binding for MC. A MC applicant who has been denied SSI within the last 12 months must be screened to determine if a DDSD referral should be completed.

DHCS Responsibility

DHCS must manually issue extended zero SOC MC to these clients. DHCS also sends a notice informing the clients that their SSI-based MC eligibility has been restored.

During the period that the SSI appeal is pending with SSA, MC eligibility will be under State control.

Related Topics

HIPAA/PII

Retroactive MC