TN 59 (02-15)

A. How we select 1619 cases for redetermination reviews

1. Section 1619(a) cases

Section 1619(a) cases are those cases where a disabled individual (DI) remains eligible for Supplemental Security Income (SSI) payments even though his or her earnings exceed the substantial gainful activity (SGA) amount. Cases that meet the 1619(a) requirements are selected for redetermination annually. These cases may meet high-error (HEP), middle-error (MEP), or low-error (LEP) criteria. For an explanation of 1619(a) status, see DI 13005.016.

2. Section 1619(b) cases

Section 1619(b) cases are those cases where a DI retains Medicaid eligibility even though he or she is in non-payment status due to excess income (N01). Cases that meet the 1619(b) requirements are selected annually as profile (W) 1619(b) MEP RZ cases. For an explanation of 1619(b) status, see DI 13005.016.

3. Continuing disability review (CDR)

The SSI system will identify 1619(a) and 1619(b) initial and status change events with an A1 (1619 initial eligibility) or an A2 (1619 potential status change) diary. For an explanation of A1 and A2 diaries, see DI 13005.016. If an A1 or A2 diary is present when conducting an RZ, follow instructions in DI 13005.018. If instructions require a CDR, attempt to schedule both the CDR and the RZ interview at the same time.

B. Age 18 critical birthday RZs

Age 18 critical birthday cases are profile K MEP RZs. We select these RZs in the month a recipient turns 18. For information on the attainment of age 18 (KB) diary, see SI 02309.003.

NOTE: Complete a disability redetermination within the year after the recipient attains age 18.

For processing Title XVI age 18 disability redetermination cases, see DI 11070.001 through DI 11070.040.

To determine the disability redetermination schedule use the Disability Control File (DCF) and the Post Entitlement Operational Data Store (PE ODS Coordinate the RZ and the disability redetermination where appropriate.

C. RZ procedures for processing 1619 cases

1. 1619(a) RZ cases

Conduct a personal contact RZ in the Modernized Supplemental Security Income Claims System (MSSICS) or on the, “Statement for Determining Continuing Eligibility for Supplemental Security Income Payments” (Form SSA-8203-BK or Form SSA-8202-BK), depending on the profile of the case. Attempt to conduct a telephone interview as the recipient is working and a face-to-face interview may be inconvenient. For instructions on completing an RZ when the recipient has gross earnings at or above SGA level, see SI 02302.030 and SI 02305.071.

2. 1619(b) RZ Medicaid while working cases

Under the 1619(b) provision of the Act, individuals who we determine to be blind or disabled are eligible for SSI payments in a subsequent month if the individual receives SSI payments for one month and is rendered ineligible for payments in a subsequent month because of his or her earned income.

To determine the individual’s eligibility for Medicaid, take the following actions:

1. Review the record to see if there is a pending CDR diary on the Title XVI record or an established Title II record and check the CDR Entitlement (ECDR) on DCF, #32 on the Main Menu to see if there is a pending CDR. For instructions on the DCF file, see DI 13005.020. If there is a pending CDR conduct both the CDR and RZ. Complete full RZ to determine if individual meets all non-disability requirements except for earned income. For coordinating RZs and CDRs, see SI 02305.016E.

2. Attempt to contact the recipient by phone as the recipient is working and a face-to-face interview may be inconvenient.

3. Obtain proof of earnings. Develop and document impairment related work expenses (IRWEs) or blind work expenses (BWEs) as appropriate. For developing work expenses during an RZ interview, see SI 02305.097 for IRWEs and SI 00820.535 for BWEs. For work expense development and documentation, see SI 00820.550.

4. Determine whether the individual continues to be eligible under Section 1619(b). For Section 1619 process and procedures, see SI 02302.030.

5. Apply the Medicaid Use Test and Threshold Test at each 1619(b) redetermination. For instructions on the tests, see SI 02302.040 through SI 02302.045.

6. For non-MSSICS cases, input the results of the Medicaid Use and Threshold Tests using the Status Indicator for Title XIX/XX (SI) field. For the SI field, see SM 01305.975.

7. Review the record to see if there is potential entitlement to Title II on his or her own work record including lag year earnings. Run the Disability Insured Status Calculator Online (DISCO) for determining entitlement to Title II disability (DIB). For information on accessing DISCO, go to http://toolbar.ssahost.ba.ssa.gov/ and click on DISCO from the Active Tools menu.

8. If there is potential Title II entitlement, follow the protective filing and closeout procedure in SI 02305.110I.

9. If you discover that any of the following events have occurred, consider whether a full RZ (MSSICS without recaps or SSA-8203) is necessary:

   • A change of marital status. For developing marital status during the RZ interview, see SI 02305.083;

   • A change in address or individuals with whom they live. For developing residence status during an RZ interview, see SI 02305.084;

   • Recipient spent a full calendar month in a hospital, nursing home or other institution. For developing institutionalization during the RZ interview, see SI 02305.086;

   • Unreported or non-posted unearned income information. For general rules for developing incomes issues during an RZ interview, see SI 02305.094. For the Post Eligibility Menu, see MSOM MSSICS 004.008.

   Close all RZ events and build transactions to the SSR. For more information on closing the RZ, see SI 02305.071.

3. Individuals ineligible for 1619(b)

Take the following actions if the recipient is no longer eligible under 1619(b):

1. Document the 1619(b) ineligibility on a Statement of Claimant or Other Person (SSA-795), person statement (DSPT), or in the report of contact (DROC) screen using MSOM MSSICS 022.010.

2. On the documentation, explain that the individual does not need Medicaid in order to work. Include on the document the name and type of other medical coverage the individual uses (e.g. HMO, other private health insurance).

3. For non-MSSICS cases, input finding of ineligibility per SM 01305.975.

4. Review the record to see if there is potential entitlement to Title II on his or her own work record including lag year earnings. Run the Disability Insured Status Calculator Online (DISCO) for determining entitlement to Title II disability (DIB). For information on accessing DISCO, go to http://toolbar.ssahost.ba.ssa.gov/ and click on DISCO from the Active Tools menu.

5. If there is potential Title II entitlement, follow the protective filing and closeout procedure in SI 02305.110I.

6. Close all RZ events and build transactions to the SSR. For more information on closing the RZ, see SI 02305.071.

D. RZ procedure for age 18 cases

Use the following procedures when developing RZs for age 18 cases (profile K):

1. Contact the recipient for a face-to-face interview for both the non-medical RZ and the disability redetermination. Face-to-face contact is preferred for disability redeterminations. For FO personal contact see, see DI 13005.030. For exceptions to personal contact, see DI 13005.035.

2. To help prepare the recipient for the interview explain that you will conduct the following two types of redetermination interviews.

   • Inform the recipient that we conduct a non-medical redetermination interview and a medical redetermination.

   • Advise the recipient to bring information and documentation pertaining to his or her living arrangement, income, and resources.

   • Advise the recipient to be prepared to provide relevant medical evidence.

3. For instructions on age 18 disability redeterminations, see DI 11070.001-040.

4. Attempt to schedule both the non-medical redetermination and the disability redetermination interviews at the same time.

5. Consider capability development and direct payment to the recipient, if appropriate.

6. Follow instructions in SI 02309.003 to complete the RZ.

E. Procedures for coordinating RZs and CDRs

For cases where the recipient is between the ages of 19 and 64, check the (DCF) for scheduled CDRs for the current year. If we already scheduled a CDR, attempt to schedule both the RZ and the CDR interviews at the same time. For additional information on Section 1619 CDRs for Title XVI recipients, see DI 13005.016 and DI 13005.018.

F. Procedures for clearing the RZ before completing CDR or disability redetermination

If you complete the non-medical RZ development, clear the RZ or close the RZ event. Non-medical RZs do not require completion of the CDR or disability redetermination and resolution of diaries associated with CDRs or disability redeterminations for clearance.

G. References

• DI 11070.001 Public Law 104-193–General through DI 11070.115

• DI 11070.040 Case Returned From the DDS

• DI 13005.016 Section 1619 CDRs for Title XVI Recipients

• DI 13005.018 Field Office Actions after 1619 Identification

• MSOM MSSICS 022.010 Report of Contact (DROC)

• MSOM MSSICS 004.008 Post Eligibility Menu (PMEN)

• SI 00820.550 Work Expense Developments and Documentation

• SI 02302.030 Section 1619 Process and Procedures

• SI 02302.040 The Medicaid Use Test for Section 1619(b) Eligibility

• SI 02302.045 The Threshold Test for Section 1619(b) Eligibility

• SI 02305.031 Type of Interview - MSSICS and Paper Forms

• SI 02305.071 Completing RZs in MSSICS or on Paper Forms SSA-8202-BK and SSA-8203-BK

• SI 02305.083 Developing Marital Status - RZs

• SI 02305.084 Developing Recipient Residence - RZs

• SI 02305.086 Developing Institutionalization - RZs

• SI 02305.094 General Rules for Developing Income Issues - RZs

• SI 02305.097 Developing Impairment Related Work Expenses (IRWE) - RZs

• SI 02305.110 Potential Eligibility for Title II Benefits - RZs

• SM 01305.975 Status Indicator for Title XIX/XX