GIS 12 MA/004: Continue Medicaid Pending a Disability Determination

The purpose of this General Information System (GIS) message is to inform local departments of social services (LDSS) that Medicaid/Family Health Plus (FHPlus) coverage must be continued in circumstances where a recipient is no longer eligible for Medicaid/FHPlus but alleges a disabling impairment and a disability determination is required to determine eligibility under the SSI-related category.

Medicaid/FHPlus coverage must be continued until a disability determination is completed for any individual who would benefit from the SSI-related category/budget and who alleges a disabling impairment at the time his/her case would otherwise have been closed or coverage reduced. For example, if a recipient in the Single/Childless Couple (S/CC) category would lose eligibility due to increased income but the individual alleges a disabling impairment and would benefit from SSI-related budgeting, coverage must be continued under the S/CC category of Medicaid until the individual's disability determination is completed. This is because Medicaid/FHPlus coverage for an individual in one eligibility category cannot be reduced or discontinued without determining whether the individual is eligible under some other Medicaid eligibility category.

Medicaid coverage shall also be continued for an S/CC-related recipient who would lose eligibility for Medicaid due to increased income and would be eligible for FHPlus but alleges a disabling impairment and would benefit from the SSI-related category/budget if determined disabled. The recipient's coverage must be continued in the S/CC category until the disability determination is complete because eligibility for Medicaid categories must be satisfied prior to enrollment in FHPlus. If an individual's disability is denied, districts must not recover Medicaid paid during the time the disability determination was being performed through the effective date of timely notice of discontinuance.