TN 24 (10-04)

A. Background – SGA

SGA determinations are required to establish initial disability for SSI but are not required for continuing SSI eligibility purposes. However, in concurrent cases, SGA determinations are necessary for continuing eligibility of Title II benefits (DI 13010.025A). SGA determinations are also required for purposes of determining reimbursement for services to vocational rehabilitation agencies (DI 13510.001) and employment networks (DI 55030.001). These determinations will in no way affect whether an individual is eligible for regular or 1619 benefits.

B. Policy – 1619(a) – earnings over SGA

An individual receiving SSI based on disability may qualify for continuing cash payments under 1619(a) in place of regular (1611) payments when his or her gross earnings are at or above the SGA level (DI 10501.015). Payment amounts under 1619(a) are calculated in the same way as regular (1611) payments.

1. Eligibility requirements for 1619(a)

a. Disability

The individual must continue to have a disabling impairment and meet all other non-disability requirements (e.g., residency, income and resources). Disability status is retained until the individual medically improves or eligibility is terminated for a non-disability reason.

b. Prerequisite month

The individual must have been eligible for and received a regular (1611) SSI cash payment based on disability for a previous month within the current period of eligibility. (An E02 month does not meet the prerequisite month requirement.) The prerequisite month does not necessarily have to be the immediate prior month. An individual can qualify for 1619(a) as early as his or her second month on the SSI rolls. (See SI 02302.010D for additional information pertinent to 209(b) States.)

NOTE: Per DI 13010.110, a return to work at the SGA level within 12 months of onset and prior to the date of the final disability determination may result in a reopening/reversal of the disability determination.

2. State supplements for 1619(a)

States which make supplementary payments (mandatory or optional, Federal or State administration) have the option of making supplementary payments to individuals eligible under section 1619(a).

a. States supplementing 1619(a) payments

b. States not supplementing 1619(a) payments

C. Policy – 1619(b) – Medicaid while working

An individual receiving SSI based on disability or blindness may qualify for continued SSI recipient status and Medicaid under 1619(b) when their earnings (alone or in combination with other income) make them ineligible for either regular 1611 or 1619(a) cash payments. By retaining SSI recipient status, an individual retains his or her rights to Medicaid eligibility (in States that follow the SSI criteria) and payment reinstatement. (See SI 02302.010D for additional information pertinent to 209(b) States.)

1. Eligibility requirements for Medicaid while working – 1619(b)

Medicaid While Working (1619(b) eligibility) only applies to the working individual. To qualify for Medicaid While Working, an individual must:

1. Continue to be blind or have a disabling impairment; and

   NOTE: Effective May 1, 1991, a person who is age 65 or older may establish eligibility under section 1619(b) provided that he or she is determined to be either blind or disabled. See SI 02302.030C.7. for instructions on obtaining a disability determination for aged individuals.

2. Meet all non-disability requirements for regular benefits except for earnings (i.e., the individual would be eligible under section 1611 if he or she had no countable earned income); and

3. Meet the prerequisite month requirement as explained above; and

4. Need Medicaid coverage to continue working (see SI 02302.040 for Medicaid Use Test); and

5. Not have sufficient earnings to replace SSI cash benefits, Medicaid benefits, and publicly-funded personal or attendant care that would be lost due to the person's earnings (see SI 02302.045 for Threshold Test).

2. Medicaid while working eligibility in couples cases

Section 1619(b) provides Medicaid While Working protection only for the working individual. Therefore, a non-working SSI eligible spouse has no protection under 1619(b) and loses Medicaid when the earned income of his or her SSI spouse causes ineligibility for a 1611 or 1619(a) payment.

However, 1619(b) provides Medicaid protection when a working individual’s total countable income, both earned and unearned (including deemed income), is too high for a cash payment. Therefore, both members of an SSI couple will be eligible for Medicaid if they are both working and their total combined income causes ineligibility for payment, even if individually, each person’s earned income wouldn’t be enough to trigger non-payment status.

3. Reinstatement rights

1. 1619(b) is a stop payment status and not a suspension status (SI 02301.201B.2.).

2. Recipient status under 1619(b) protects reinstatement rights under all SSI provisions (i.e., regular 1611 or 1619(a) cash benefits, or 1619(b) benefits).

3. Individuals eligible under section 1619(b) are reinstated to cash benefit status if countable income drops below the applicable breakeven point (as explained in SI 00810.350) and all other eligibility criteria are met.

4. Reinstatement is possible at all times in all States, unless the individual's eligibility is terminated. Therefore, 1619(b) eligibility development is required in all States.

NOTE: See SI 01210.300 regarding loss of income grandfathering protection for converted blind recipients.

D. Policy – 209(b) states

1619(a) or (b) eligibles who reside in 209(b) States must have been eligible for Medicaid in the month immediately prior to becoming eligible for 1619 status to retain their Medicaid eligibility. The 209(b) States are: Connecticut; Hawaii; Illinois; Minnesota; Missouri; New Hampshire; North Dakota; Ohio; Oklahoma; and Virginia (SI 01715.010).

E. Policy – suspensions and terminations

1. Non-disability requirements not met

A recipient who does not meet a non-disability requirement in a month (other than income), is placed in suspense until the next month in which all requirements can be met for 1619(a), 1619(b), or regular 1611 benefits.

2. Disability cessation

If, at any time, an SSI eligible is found to no longer have a disabling impairment, his or her disability is ceased effective with the month of that determination. Regular 1611 or 1619(a) cash benefits or SSI recipient status under 1619(b) continue(s) for that month and the following 2 months (i.e., the grace period) if all non-disability criteria are met. The individual's eligibility is terminated after the grace period and a new application, a new disability determination, and a new prerequisite month are required for a blind or disabled individual to reestablish eligibility.

F. Policy – Medical facilities

If a 1619 eligible enters a public medical or psychiatric facility or a Medicaid facility (as described in SI 00520.001), he or she may be eligible to receive a benefit based on the full Federal Benefit Rate (FBR), plus appropriate State supplement, for up to 2 months. See SI 00520.130 for a detailed discussion of this provision.

G. Policy – CDR and Medical Folder Reviews

1. Medical Folder Reviews (MFR)

Prior to December 1999, an MFR was required on 1619(a) and 1619(b) cases to determine whether a medical CDR was needed.

2. CDR

The system will identify 1619(a) and 1619(b) cases for review with an A1 or an A2 diary (see DI 13005.016). Follow instructions in DI 13005.018 to determine when a CDR is required based on the A1 or A2 diary.

NOTE: Do not conduct a CDR on a 1619 case more than once in any 12-month period.