2680 Protected Medical Groups (Pickle Amendment, Early/Disabled Widows and Widowers, etc.) - The following groups of individuals may qualify for medical assistance without a spenddown (or without a liability in the HCBS program) except for persons convicted of medical fraud or who have a special spenddown. (See 11221 (5) and 11126.1 (5).) The appropriate criteria established below must be met.

 

2681 Pickle Amendment - Based on a March 1984 District Court decision, persons who have lost their SSI eligibility (including eligibility under section 1619 per 2634) may qualify for medical assistance without a spenddown if they meet the following criteria:

 

  1. They are now receiving OASDI benefits;
     
  2. They were eligible for and received OASDI and SSI benefits concurrently during any month since April 1977; 

  3. They have lost eligibility for SSI since April 1977; and
     
  4. They would now be eligible for SSI benefits if the total amount of all OASDI cost of living adjustments (COLA's), including those of a non-Pickle qualifying spouse, parent, or other legally responsible family member, received since they became ineligible for SSI were deducted from their current income.
     

Those persons who lose their SSI eligibility due solely to an OASDI cost-of-living increase will qualify based on the provisions above. This provision is not applicable to those who (1) currently receive SSI or cash assistance, or (2) who reside in a nursing facility or state institution. In addition, an individual who was terminated from SSI because he or she was awarded initial OASDI benefits will not be eligible because there was never concurrent eligibility for both programs in the same month.

 

Qualifying individuals must meet all MS nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections. The one person allowable nonexempt resource level shall be applicable for an individual and the two person level for an individual who is living together with his or her spouse, parent, or other legally responsible family member (whether or not the member is a cash or medical recipient or eligible for Pickle status as well).

 

All aged and disabled OASDI recipient who apply for or are interprogram transferred to MA and MS shall be screened for eligibility under the Pickle Amendment. If all screening criteria are met, an income determination is to be completed. The Determination Worksheet for Pickle Eligibles and

 

Other Protected Medical Groups (ES-3104.6) is to be used for this purpose. Verification must be provided by the individual of his or her SSI termination date, previous concurrent OASDI/SSI status, and current OASDI benefit amount.

 

An income determination is not required for those SSI recipients who lose their SSI eligibility at the time of an OASDI cost-of-living increase and are interprogram transferred to MS. The Pickle code for persons with excess income as noted below shall be reflected for those who lose their SSI eligibility at any time other than a COLA increase.

 

To determine total countable income, the person's countable OASDI amount must first be computed by subtracting the COLA amount to be disregarded from the current gross OASDI monthly benefit.

 

The COLA disregard is determined by using the ratio from the COLA Ratio Table at the bottom of the worksheet which corresponds to the time period in which the individual received his or her last SSI payment and multiplying that ratio by the OASDI benefit. The disregard is to be rounded down to the nearest penny. A countable OASDI amount shall also be computed for the individual's spouse, parent, or other legally responsible family member, if living together (excluding HCBS arrangements), whether or not that person also qualifies for Pickle eligibility. Both amounts shall be computed separately and then combined.

 

The countable OASDI amount is then added to all other gross income. For individuals who live with a legally responsible family member (whether that person qualifies for Pickle eligibility or not), all other income of the member must also be considered in the determination. The total countable income obtained shall be compared to the current appropriate SSI benefit level.

 

For individuals living alone or living in someone else's household, the total countable income shall be compared to the one person SSI benefit level or prorated one person benefit level respectively. For individuals living with a spouse who has no income, the one person SSI benefit level (or prorated level if in someone else's household) shall be used. For individuals living with a spouse who has income or also qualifies for Pickle eligibility, the two person SSI benefit level (or prorated level if in someone else's household) shall be used. In all other situations, a one person SSI benefit level shall be used.

 

If the total countable income is less than the appropriate SSI benefit level, there is eligibility for Pickle status. Medicaid eligibility would be provided with no spenddown requirement beginning with the first eligibility base period (including prior medical, if requested).

 

Pickle cases shall be established under the MS program and identified by a Pickle code. (See the KAECSS S User Manual.)

 

If the total countable income is greater than the appropriate SSI benefit level, there is no eligibility for Pickle status currently. Such individuals may qualify at the time of a future OASDI COLA increase. If a regular determined medical case is established, the appropriate Pickle code must be reflected. (See the KAECSS S User Manual.)

 

Persons eligible for Pickle status shall be reviewed on an annual basis in accordance with 9372. If there has been no change in circumstances during the year such as a change in entitlement status, increase in other income, or change in living arrangement, Pickle eligibility will continue. Persons who do not qualify for Pickle eligibility because of excess income and who retain eligibility for medical must be reviewed at the time of each COLA increase.

 

Although persons qualifying for Pickle status will be eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus, the income and resources of a person receiving medical under the Pickle Amendment would be considered in determining the cash and medical eligibility of his or her non-Pickle eligible spouse and minor child.

 

2682 Qualifying Disabled Widows and Widowers - Based on a provision contained within the Consolidated Budget Reconciliation Act of 1985 (COBRA) persons who lose their SSI eligibility (including eligibility under section 1619 per 2634) because of an increase to their Social Security disabled widow's or widower's benefits may qualify for medical assistance without a spenddown if they meet all of the following criteria:

 

  1. They were entitled to a monthly Social Security benefit for December 1983;
     
  2. They were entitled to and received a Social Security widow's or widower's benefit for January 1984 based on a disability;
     
  3. They became ineligible for SSI benefits because of an increase in the amount of their widow's or widower's benefit which was caused by the elimination of a reduction factor for disabled widows and widowers who became entitled before age 60;
     
  4. They have been continuously entitled to a disabled widow's or widower's benefit since that increase was received; and
     
  5. They would be eligible for SSI benefits now if the amount of that increase and any cost-of-living adjustments since then were deducted from their current income.

 

This provision is not applicable to those who (1) receive SSI or cash assistance or (2) reside in a nursing facility or state institution. Qualifying individuals must meet all MS nonfinancial eligibility factors including the general eligibility requirements of 2100 and the resource criteria of 5000 and subsections.

 

Application for eligibility under this provision must be made prior to July 1, 1988. Each state received information from SSA identifying all persons residing in that state who potentially qualified under this provision. Thus, persons applying for eligibility under this provision in Kansas must present evidence of having been notified of their potential eligibility or of having qualified for assistance under this provision. Persons who qualified prior to July 1, 1988 in another state and who move to Kansas can be determined eligible here if continued coverage under this provision is requested.

 

Verification of their eligibility status in the other states is required. Persons who were notified of their potential eligibility in another state but did not apply and who later move to Kansas must apply for benefits under this provision prior to July 1, 1988.

 

If the above evidence is presented, an income determination shall be completed. The amount of the person's Social Security benefit prior to the reduction factor increase and any subsequent COLAs must be verified. This amount shall be added together with all other current nonexempt gross income. The MS income disregards as described in 7240 shall be applied to the total income. The countable income obtained shall then be compared to the current SSI benefit level for 1 person (either the full amount or the prorated amount if living in someone else's household).

 

The Determination Worksheet for Pickle Eligibles and Other Protected Medical Groups (ES-3104.6) shall be used for determining countable income by using Lines 3-9. The person's Social Security benefit prior to the reduction factor increase would be inserted on Line 3.

 

If the total countable income is less than the appropriate SSI benefit level, the person qualified for medical eligibility without a spenddown. Such eligibility shall begin with the first eligibility base period (including prior medical, if requested).

 

If the total countable income is greater than the appropriate SSI benefit level, the person does not qualify and a regular medical determination shall be developed.

 

Persons eligible under this provision shall be reviewed on an annual basis in accordance with 9372. If there has been no change in circumstance such as an increase in other income or loss of disabled widow or widower status, such eligibility shall continue. Although qualifying persons are eligible for medical without a spenddown as though they were receiving SSI benefits, they are not to be viewed as SSI recipients for any other purpose. Thus the income and resources of a person receiving medical under this provision would be considered in determining the cash and medical eligibility of any dependent children.