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SI 02302: Continuing Benefits and Recipient Status Under Sections 1619(A) and 1619(B) for Individuals Who Work

Effective Dates: 11/18/2014 - Present

TN 11 (09-92)

A. Policy

1. General

To be eligible for 1619(b), an individual must depend on Medicaid coverage to continue working.

An individual depends on Medicaid coverage if he/she:

Used Medicaid coverage within the past 12 months; or
Expects to use Medicaid coverage in the next 12 months; or
Would be unable to pay unexpected medical bills in the next 12 months without Medicaid coverage.

2. When to Make Determination

a. Initial Determination

The initial Medicaid use determination is made at the time the individual reports earnings which will cause ineligibility for cash payment.

EXCEPTION: If this would require an additional contact with the recipient (e.g., the earnings were reported by mail), the determination is deferred until the next scheduled redetermination.

b. Subsequent Determinations

Subsequent Medicaid use determinations are made at each scheduled 1619 redetermination.

B. Procedure

Follow this procedure each time a Medicaid use determination is made:

Step	Action
1	Ask the individual the following questions: “Have you used any medical care or services in the past 12 months that was paid for by Medicaid (or Medi-Cal, etc.)?” “Do you expect to receive any medical care or services in the next 12 months that will be paid for by Medicaid (or Medi-Cal, etc.)?” “Without Medicaid (Medi-Cal, etc.), would you be unable to pay your medical bills if you become ill or injured in the next 12 months?” Rephrase the questions, as necessary, to fit the individual's understanding.
2	If the individual answers “yes” to any of the questions in Step 1: Record the individual’s allegation regarding use of Medicaid on a Report of Contact, SSA-795, or on the MSSICS DPST or DROC screen. Transmit a finding that the individual meets the use test to the system per SM 01305.975. Proceed with development and documentation of sufficiency of earnings (i.e., the threshold test), per SI 02302.045.
3	If the individual answers “no” to all of the questions in step 1: Be sure the response is well-founded given the individual's situation. A negative response is appropriate only when there are sufficient alternate sources available to the individual to pay for his/her medical care (e.g., comprehensive medical coverage through health insurance or membership in a health plan, access to other health programs). Record the allegation on a Report of Contact, SSA-795, or on the MSSICS DPST or DROC screen. To avoid potential misunderstandings, include the name and type of the individual’s other medical coverage, e.g., “Cummings, Inc. employee health plan – Kaiser HMO.” Transmit the finding of ineligibility to the SSR per SM 01305.975.

Step

Action

Ask the individual the following questions:

“Have you used any medical care or services in the past 12 months that was paid for by Medicaid (or Medi-Cal, etc.)?”
“Do you expect to receive any medical care or services in the next 12 months that will be paid for by Medicaid (or Medi-Cal, etc.)?”
“Without Medicaid (Medi-Cal, etc.), would you be unable to pay your medical bills if you become ill or injured in the next 12 months?”

Rephrase the questions, as necessary, to fit the individual's understanding.

If the individual answers “yes” to any of the questions in Step 1:

Record the individual’s allegation regarding use of Medicaid on a Report of Contact, SSA-795, or on the MSSICS DPST or DROC screen.
Transmit a finding that the individual meets the use test to the system per SM 01305.975.
Proceed with development and documentation of sufficiency of earnings (i.e., the threshold test), per SI 02302.045.

If the individual answers “no” to all of the questions in step 1:

Be sure the response is well-founded given the individual's situation. A negative response is appropriate only when there are sufficient alternate sources available to the individual to pay for his/her medical care (e.g., comprehensive medical coverage through health insurance or membership in a health plan, access to other health programs).
Record the allegation on a Report of Contact, SSA-795, or on the MSSICS DPST or DROC screen. To avoid potential misunderstandings, include the name and type of the individual’s other medical coverage, e.g., “Cummings, Inc. employee health plan – Kaiser HMO.”
Transmit the finding of ineligibility to the SSR per
SM 01305.975.

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SI 02301: Posteligibility Changes

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SI 023: Posteligibility Events

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SI 02305: Redeterminations of Eligibility and/or Payment Amount

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