Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 477 - MEDICAID ELIGIBILITY
Chapter 27 - ELIGIBILITY FOR THE AGED, BLIND, AND DISABLED; MEDICALLY NEEDY; QUALIFIED DISABLED WORKING INDIVIDUALS; MEDICAID INSURANCE FOR THE WORKERS WITH DISABILITIES; BREAST AND CERVICAL CANCER; EMERGENCY MEDICAL SERVICES ASSISTANCE; AND KATIE BECKETT
Section 477-27-002 - AGED, BLIND, AND DISABLED (ABD)

Universal Citation: 477 NE Admin Rules and Regs ch 27 § 002

Current through September 17, 2024

Medicaid for aged, blind, and disabled (ABD) provides medical coverage for individuals who meet the criteria specified below.

002.01 MANDATORY GROUPS. Certain individuals are eligible to receive Medicaid in the aged, blind, and disabled (ABD) category due to current or prior participation in the Supplemental Security Income (SSI) program. A separate application for Medicaid must be submitted before eligibility can be determined.

002.01(A) SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. Nebraska residents who are currently receiving benefits from the Supplemental Security Income program are eligible to receive Medicaid in the aged, blind, and disabled (ABD) category. The Supplemental Security Income (SSI) program is responsible for verifying the individual's income, resources, and the determination that an individual is disabled.

002.01(B) 1619B BENEFICIARIES. A blind or disabled individual is eligible if the individual received Medicaid and Supplemental Security Income (SSI) in the month before the month in which this reference applies and whose Supplemental Security Income (SSI) payment stopped due to the level of earnings and who is determined by the Social Security Administration (SSA) to have special Medicaid status under section 1619(b) of the Social Security Act, as amended. The Social Security Administration (SSA) is responsible for verifying the income, resources, disability status, and 1619(b) eligibility of the individual.

002.01(C) FORMER SUPPLEMENTAL SECURITY INCOME (SSI) RECIPIENTS. Certain former recipients of benefits from the Supplemental Security Income (SSI) program remain eligible for Medicaid benefits after losing the ability to receive Supplemental Security Income (SSI) program benefits. For each category below, all of the following requirements must be met in order to be considered a member of the category.

002.01(C)(i) DISABLED EARLY WIDOWS OR WIDOWERS. These individuals are also referred to as additional reduction factor (ARF) widows or widowers. All of the following must be met:

(1) Have been determined disabled;

(2) Were receiving Supplemental Security Income (SSI) in December, 1983 and lost Supplemental Security Income (SSI) benefits in January, 1984 due to the elimination of a benefit reduction factor for widows or widowers before the attainment of age 60;

(3) Have been continuously entitled to the Title II widow or widowers benefit based on disability since January, 1984;

(4) Applied for benefits under this group prior to July 1, 1988 or a later date established under the court order in Darling v. Bowen; and

(5) Would continue to be eligible for Supplemental Security Income (SSI) benefits, including the resource standard, if the client had not received the increase in Title II benefits.

002.01(C)(ii) DISABLED ADULT CHILDREN (DAC). This population is also known as childhood disability beneficiaries (CDB). All of the following must be met:

(1) Lost Supplemental Security Income status after November 10, 1986 due to the mandatory receipt or increase in Title II benefits on a parent's record due to the retirement, death, or disability of the parent;

(2) Are age 18 or older;

(3) Blindness or disability began before age 22; and

(4) Would continue to be eligible for a Supplemental Security Income (SSI) payment, including the resource standard, if they were not receiving the Title II disabled adult child benefit.

002.01(C)(iii) SECTION 503 GROUP. This population is commonly referred to as the Pickle Amendment Group. All of the following factors must be met:

(1) Is currently receiving Title II income;

(2) Was eligible for and receiving Supplemental Security Income (SSI) benefits concurrently with Title II income for at least one month after April 1, 1977; and

(3) Lost Supplemental Security Income (SSI) benefits, but would continue to receive it, including the resource standard, if the amount of cost-of-living increases received from Title II income after the month in which Supplemental Security Income (SSI) benefits were lost were deducted from the current Title II benefit. The cost-of-living increases include the increases received by the individual, the individual's spouse, or a financially responsible family member.

002.01(C)(iv) EARLY WIDOWS OR WIDOWERS. This population is also known as COBRA widows or widowers. All of the following factors must be met:

(1) Lost Supplemental Security Income (SSI) benefits due to the mandatory receipt of Title II benefits;

(2) Is not yet eligible for Medicare Part A;

(3) Has attained age 50, but is not yet age 65; and

(4) Would continue to be eligible for Supplemental Security Income (SSI) if not receiving Title II benefits.

002.02 AGED, BLIND, AND DISABLED (ABD) 100% GROUP. Aged, blind, and disabled individuals who are not eligible as a member of a mandatory group may be eligible for Medicaid if all of the criteria below are met. Members of this group are entitled to all benefits under the state plan. The eligibility factors below are in addition to the requirements in chapters three, five, six, and eight of this title.

002.02(A) INCOME. Countable income for the individual must be at or below 100% of the Federal Poverty Level (FPL). Countable income is determined according to the provisions of chapter 22 of this title.

002.02(B) RESOURCES. Countable resources must be at or below the limit specified in chapter 23 of this title. The provisions of chapter 23 will determine whether or not a resource is countable toward the specified limit.

002.02(C) CATEGORICAL FACTORS. An individual must meet the categorical factors of age, blindness, or disability, as defined below.

002.02(C)(i) AGE. An individual is considered a member of the aged category at age 65 or older. A blind or disabled individual becomes a member of the aged category the month that the individual turns age 65.

002.02(C)(ii) BLINDNESS OR DISABILITY. All applicants requesting eligibility in the blind or disabled category must meet the medical definitions of blindness or disability of the Retirement, Survivors, and Disability Insurance (RSDI) or the Supplemental Security Income (SSI) programs as administered by Social Security Administration (SSA). The determination by the Social Security Administration (SSA) that an individual is disabled or blind must be accepted for eligibility for the aged, blind, or disabled (ABD). In some cases, the State Review Team (SRT) may make the determination of blindness or disability.

002.02(C)(ii)(1) DISABILITY CRITERIA. Generally, an individual is disabled if the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months. A child through 17 years old is considered disabled if the child suffers from any medically determinable physical or mental impairment of comparable severity. See Titles II and XVI of the federal Social Security Act, as amended, for further disability criteria. The Social Security Administration has the primary responsibility of determining whether an individual meets the disability criteria.

002.02(C)(ii)(1)(a) DETERMINATIONS UNDER APPEAL. An individual who is determined ineligible for Medicaid for the aged, blind, or disabled (ABD) because the individual does not meet the disability requirements of the Supplemental Security Income (SSI) program may appeal the decision to the Social Security Administration (SSA). Upon receiving an affirmative redetermination of disability from the Social Security Administration (SSA), the Department shall use the corresponding date of application in determining eligibility for Medicaid if the individual meets all of the following:

(i) Has been determined ineligible for the Supplemental Security Income (SSI) program because the individual is not considered disabled due to lack of severity;

(ii) Appeals the decision of the Supplemental Security Income (SSI) program; and

(iii) The individual wins the appeal.

002.02(C)(ii)(2) DIRECT REFERRAL TO THE STATE REVIEW TEAM. In the following situations a referral may be submitted directly to the state review team (SRT) for a determination of disability and its probable duration without waiting for a determination from the Supplemental Security Income (SSI) program if the individual is not eligible for another medical program, and during the initial intake it is apparent that:

(A) The individual has income and/or resources in excess of the limit for the Supplemental Security Income (SSI) program. The individual's potential eligibility for the Supplemental Security Income (SSI) program must be monitored. If income or resources fall below the Supplemental Security Income (SSI) limit, an immediate referral for the Supplemental Security Income (SSI) program must be made to the Social Security Administration (SSA). The individual is allowed 60 days to apply for this potential benefit;

(B) The individual requires immediate long-term hospitalization or treatment for a severe impairment before the Social Security Administration (SSA) can make a determination for the Supplemental Security Income (SSI) program, or the individual would be required to extend a hospital stay solely because of a delay in processing the Supplemental Security Income (SSI) application. An immediate referral for the Supplemental Security Income (SSI) program must be made;

(C) The individual is residing in a medical facility or public institution and the Social Security Administration (SSA) will be unable to make a disability determination for the Supplemental Security Income (SSI) program. An individual is eligible for Supplemental Security Income (SSI) benefits while institutionalized only if Medicaid will pay 50 percent of the individual's care. Therefore, the Social Security Administration (SSA) may, in some cases, wait for a determination of eligibility for Medicaid. An immediate referral for the Supplemental Security Income (SSI) program must be made;

(D) The individual is deceased and the Social Security Administration (SSA) will not make a disability determination for the Supplemental Security Income (SSI) program; or

(E) The individual is a non-citizen who the Social Security Administration (SSA) will not review for the Supplemental Security Income (SSI) program.

002.02(C)(ii)(2)(a) DOCUMENTATION STANDARD. The state review team (SRT) will review medical documentation dated no more than 12 months prior to the date for which a disability determination is requested. The individual whose disability status is being determined must have been examined by a physician, or appropriate provider, for the condition or conditions related to the disability determination within three months of the requested date.

002.02(C)(ii)(2)(b) REFERRALS TO THE SOCIAL SECURITY ADMINISTRATION. The Department must continue to monitor the individual's potential eligibility for Retirement, Survivors, Disability Insurance (RSDI) and Supplemental Security Income (SSI) benefits even though the state review team (SRT) has made the determination of disability. A referral for the Supplemental Security Income (SSI) or Retirement, Survivors, Disability Insurance (RSDI) program, as appropriate, must be made at the time of the state review team (SRT) determination. If the individual is denied benefits under the Supplemental Security Income (SSI) or Retirement, Survivors, Disability Insurance (RSDI) programs initially for a non-disability related reason, but later appears to be eligible for such benefits, then a referral must be made. The individual's referral will allow 60 days to apply for the potential benefits.

002.02(C)(ii)(2)(c) SOCIAL SECURITY DETERMINES THE INDIVIDUAL IS NOT DISABLED. If the state review team (SRT) has determined the individual is disabled but, the Social Security Administration (SSA) later determines that the individual is not disabled due to lack of severity or the ability to engage in substantial gainful activity, then the Department will abide by the decision of the Social Security Administration. If the individual has filed an appeal with the Social Security Administration (SSA), the individual must be considered disabled through the review period established by the state review team (SRT). If no appeal with the Social Security Administration (SSA) is filed, then the disability requirement cannot be considered to be met.

002.02(C)(iii) SUSPENSION OF BENEFITS. If Supplemental Security Income (SSI) benefits are suspended due to excess income or excess resources, the individual is still considered disabled for a period of 12 consecutive months, as long as all other eligibility factors are met. The 12 month period is effective the first day of the month in which the benefits are suspended. To continue Medicaid eligibility for the aged, blind, or disabled (ABD) category at the end of the 12 month period, a review of disability by the state review team (SRT) is necessary.

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