Definition of Other Benefits
Other benefits include, but are not limited to, annuities, pensions, Title II benefits (Social Security retirement, early retirement, survivors and disability benefits), unemployment insurance, and Medicare Part B.
Policy Requirement
Income Benefits.
Medicaid applicants and recipients must take all necessary steps to receive all income benefits or increases in income benefits to which they are entitled, unless they can show good cause for not doing so. They must apply for and accept the highest benefit amount available to them. A claim for good cause does not include the reason that receiving benefits or an increase in income benefits would cause the person to lose Medicaid eligibility, have a spenddown or have a higher spenddown.
Applicants and recipients must apply to receive the benefits in a monthly payment rather than as a lump sum, if monthly payments are an option. They must elect to receive the highest amount to which they are eligible, which means that they cannot accept a reduced amount to allow for a survivor's benefits.
Lump sum payment only: If an individual can only access an available benefit in the form of a lump sum payment, such as a retirement fund from a former employer, the individual is not required to apply to receive it because it is not a source of income. This can occur because the individual does not meet criteria to receive the money as a monthly retirement payment. Rather the funds are considered an asset subject to any applicable asset counting rules.
Medicare benefits.
Individuals who are eligible to receive Medicare must apply for Part B benefits if they are not already receiving Medicare, and the Medicare benefits will not begin automatically. See 223-2 for details.
Medicare Part B starts automatically when an individual is receiving Social Security benefits and reaches the applicable eligibility date. No application is required.
If an individual already has Part A Medicare, but is not enrolled in Part B, the Part B enrollment will occur automatically when the individual becomes eligible for Medicaid or a Medicare Cost-Sharing program. The individual does not have to apply for Part B with Social Security.
The Medicare number is required to start the BUY-IN process.
Minor children receiving survivor's benefits and spouses under age 65 who are receiving survivor's benefits based on caring for young children are not entitled to Medicare benefits and are not required to apply for Medicare to be eligible for Medicaid.
When a child or incapacitated person may qualify for other benefits, the parent, guardian or responsible person must take all steps to apply for and receive such benefits. If the parent, guardian or responsible person does not take steps to receive such benefits, the child or incapacitated person is ineligible for Medicaid.
Income Benefits
Applicants and recipients must apply for the following income benefits if circumstances indicate they may be eligible.
Social Security Retirement, Survivors, Disability Insurance and Early Retirement when the individual is age 62 or older and either has a work history or has been married for at least 10 years to an individual who has a work history.
An individual under full retirement age who claims to be disabled and has a work history must apply for disability insurance.
An individual age 62 or older, who has a work history must apply for early retirement, or regular retirement. If the individual is not at full retirement age and claims to be disabled, or is determined disabled by the MRB, the individual must also apply for disability benefits.
Do not require an individual who does not have sufficient work history to apply for disability benefits under his or her own Social Security record. [NOTE: Social Security disability insurance requires a different number of covered work quarters for different aged workers.]
Spouses of an insured person may be eligible for early retirement at age 62 and regular retirement if they are of full retirement age.
Children of an insured person may be eligible for survivor's benefits if the insured person is deceased, or is receiving SS disability or retirement benefits.
Children who became disabled before age 22 may be eligible for a Disabled Adult Child benefit if the insured parent is deceased, or is receiving SS disability or retirement benefits.
Individuals who do not receive VA benefits must apply for them or for increased payments, if they could possibly be eligible. (See Sec. 223-4)
Do not require the individual to apply for such benefits if the benefit does not count as income. This includes VA Aid and Attendance and some benefits for veteran's children. (See Sec. 415-2)
An individual whose eligibility is determined using MAGI-based methodologies does not have to apply for VA benefits, as these benefits do not count as income under the MAGI-based methodology.
Railroad Retirement (retirement, survivor or disability)
Civil Service, federal, state, or local government (retirement, disability or survivor benefits), or military retirement or military survivor's benefits.
Unemployment Compensation or Worker's Compensation funds.
Other similar benefits such as private retirement or disability benefits. This includes non-governmental benefits such as making money available from trust funds and inheritances. Do not require a person to apply for a retirement pension if the person is still working and would have to quit working to receive the benefits.
Survivor's Benefits. Some of the above programs provide benefits for spouses and divorced spouses age 62and older; widow/widower and disabled widow/widower benefits; surviving minor child or disabled adult child benefits; and benefits for a spouse caring for young children. Individuals who may qualify for these benefits must apply for them. A change in circumstances in a person's life may make the person eligible for these benefits.
Income available from an institutionalized or waiver-eligible spouse.
Applicants and recipients must also take steps to receive income available from a Medicaid-eligible spouse in a nursing home, or a spouse eligible under certain home and community waivers under the policy that allows a deduction from the institutionalized spouse's income for a community spouse. However, the nursing home or waiver spouse can choose to contribute all, part or none of the allowed spousal income deduction to the community spouse.
Do not deny Medicaid to a community spouse because of the decision made by the nursing home or waiver spouse. Count as income only the actual amount given to the community spouse. The allowed deduction from income of the nursing home or waiver spouse must equal the amount actually contributed to the community spouse.
Benefits Individuals Do Not Have To Apply For
Applicants and recipients are not required to apply for SSI benefits, FEP benefits or crime victim's compensation funds.
Applicants and recipients do not have to apply for benefits that do not count as income for Medicaid purposes. This includes things such as VA Aid and Attendance, earned income tax credits, Victim's Compensation funds, or for MAGI-based eligibility groups any Veteran's benefits. (See sec. 415-2 and 417 on income exclusions.)
Household members who will not be receiving medical assistance are not required to apply for benefits to which they may be entitled. This is true even if we deem income or would deem income from that person.
Applicants and recipients are not required to apply for Advanced Premium Tax Credits through the Exchange.
Time Allowed to Apply for Benefits
When you decide an applicant or a recipient may be eligible for other benefits, tell the individual in writing what benefits he is required to apply for and the due date for verification.
If the agency has the needed information that shows an applicant is eligible for Medicaid, and the only other thing needed is to apply for other possible benefits, approve the Medicaid application. Notify the individual of the requirement to apply for other possible benefits. If a change in an ongoing individual's situation could make the individual eligible for benefits, notify the individual and give him time to verify applying for other benefits. Do not close benefits before the due date for applying for other benefits.
Allow the individual at least 30 days from the notice date to verify applying for other benefits, (at least 90 days if applying as disabled.) If an individual is required to apply for Medicare Part B benefits, allow the member at least 90 days to apply.
If the due date is a non-business day, the due date becomes the business day following that due date.
The member must verify that he has applied for the other benefits.
If the member requests more time, give the member more time to file an application for the other benefits and provide verification to the agency. Verification is due by the close of business on the due date to be considered received timely.
The member must continue to do what is needed to complete the application process and receive a decision about the benefits, such as providing verification to the pertinent agency.
If the member does not apply, fails to take other steps to complete the process, or fails to claim good cause for not applying, close the case. Reopen the case if the member verifies before the closure date that he has applied, is taking additional steps to get other benefits or has good cause for not applying.
If eligibility ends for a household member due to failure to apply for other benefits and the household case remains open, treat the date the individual verifies applying for other benefits as a new application date.
If the Medicaid case closes, and the individual reapplies for medical assistance, notify the individual that he is still required to apply for other possible benefits.
Claiming Good Cause
If a individual claims good cause for not applying for other benefits, ask the individual for a written statement with the reason for the good cause. Request verification if needed.
Good cause may exist if the individual lacks sufficient information about the insured person under whose work history benefits may be available.
Social Security, or other agencies, may not be able to match records without sufficient information to assure the identity and relationship of the insured person and the applicant.
If the individual cannot get the needed information, or if getting that information would cause possible harm to the individual or family, good cause may exist.
Agencies like Social Security do not contact the insured person when a person applies for benefits under the insured person's work history. Therefore, fear of harm from the insured person because the individual applies for Social Security should not be a reason for not applying as long as the individual has sufficient information about the insured person to file.
Review Sec. 225-4 on good cause reasons for not cooperating with TPL. The reasons and evidence requirements can be similar.
Contact the OEP Program Specialist, if you need to discuss whether good cause exists.
If the member establishes good cause, continue Medicaid. Update the good cause claim at each renewal if it still exists. If good cause no longer exists at renewal, notify the member of the requirement to apply for other benefits. If the member fails to apply for other benefits, close the Medicaid case.