Citations:

Social Security Act—Sections 1619, 1634, 1902, 1905 and 1928
Section 503 of Public Law 94-566

Regulations 20 CFR 416.2101-.2176 (Subpart U)
Regulations 42 CFR 435.120-.135, 435.230, 435.320-.330, 435.909

TN 2 (08-92)

A. Introduction

The importance of Medicaid to supplemental security income (SSI) beneficiaries cannot be overemphasized. The aged, blind and disabled need medical coverage. Since Medicaid flows from SSI payments in most States, qualifying for SSI payments to get Medicaid can be the most important aspect of the SSI program for a beneficiary.

Each State requests approval of its Medicaid Plan from the Centers for Medicare & Medicaid Services (CMS). Although the State Medicaid Plans differ, they all provide medical coverage for at least some SSI beneficiaries in all 50 States, the District of Columbia and the Commonwealth of the Northern Mariana Islands (NMI).

NOTE: The following addresses parts of Medicaid that affect the aged, blind and disabled. For the most part, it leaves out those parts of Medicaid that affect families with dependent children.

B. Background

Title XIX of the Social Security Act (the Act), known as Medicaid in most States (Medi-Cal in California; in Arizona it is called AHCCS, the Arizona Health Care Cost Containment System) provides Federal cost-sharing for each State"s medical assistance program. The Federal government pays 50 percent of Medicaid administrative costs and between 50 and 83 percent of program costs following a statutory cost-sharing formula.

The Medicaid statute requires coverage of mandatory groups and gives States the option to provide Medicaid to various other groups.

C. Policy

1. Statutory Groupings

In general, the Medicaid statute divides State plan coverage into three separate groupings:

• The mandatory groups; i.e., individuals who must be covered by any State that has a Medicaid program, such as the mandatory categorically needy;

• The optional categorically needy; i.e., categories of groups that a State may elect to cover; and

• Other coverage groups, such as the medically needy and individuals covered under a waiver.

See .005 below for additional information on these groups.

2. Eligibility — General

To be potentially eligible for any Medicaid coverage, an individual must be in a category addressed by a cash assistance program, such as the aged, blind and disabled (or as a member of a family with dependent children as defined in the Aid to Families with Dependent Children (AFDC) program). Individuals who do not belong to a covered category cannot get Medicaid.

Medicaid is a cost-shared, Federal-State program. There are other types of medical assistance programs that are not cost-shared under title XIX of the Act. Those are not  Medicaid.

EXAMPLE: A State may provide medical assistance to individuals who receive general assistance who are not eligible for SSI. Information about medical assistance which is not Medicaid may be available to the field office (FO) from materials issued by the regional office (RO) or local sources. FO"s refer individuals for all types of medical assistance that may be available, not just Medicaid.

3. Retroactivity

The Medicaid statute requires retroactive coverage of covered medical expenses for up to 3 months before the Medicaid application if the individual would have been eligible at that time. Retroactivity is very important. (Instructions for situations in which the individual dies while the application is pending are located in SI 01730.015.) In the 1634 States (discussed in .010 A.3. below, also see chart in .020 below), the SSI application also serves as the Medicaid application.

Medicaid retroactivity can be an important element in an individual"s selection of the application effective date for SSI (SI 00601.009).

Some States provide retroactivity for up to 3 months before the day of effective filing; others, up to three months before the month of effective filing.

NOTE: Retroactivity does not apply to Qualified Medicare Beneficiaries (QMB"s), a group discussed in .005 A.5. below.

D. References

• Application Effective Date, SI 00601.009

• Disability Determinations for Deceased Claimants to Establish Medicaid Eligibility, SI 01730.015