Medicaid Eligibility Determinations

20 C.F.R. Part ..., Subpart U
in effectEffective: 2024-07-01

20 C.F.R. § 416.2101 Introduction.

(a) What is in this subpart. This subpart describes the agreements we make with States under which we determine the Medicaid eligibility of individuals who receive Supplemental Security Income (SSI) benefits. It includes a general description of the services we will provide under these agreements and the costs to the States for the services. (b) Related regulations. The comprehensive regulations on eligibility for the Medicaid program, administered by the Health Care Financing Administration, are in part 435 of title 42 of the Code of Federal Regulations. (c) Definitions. In this subpart— SSI benefits means Federal SSI benefits, including special SSI cash benefits under section 1619(a) of the Social Security Act. In addition, we consider a person who has special SSI eligibility status under section 1619(b) of the Social Security Act to be receiving SSI benefits. State Medicaid Plan means a State's medical assistance plan which the Secretary has approved under title XIX of the Act for Federal payment of a share of the State's medical assistance expenses. State supplementary payments means supplementary payments we administer for a State under subpart T of this part. We, us, or our refers to the Social Security Administration.

20 C.F.R. § 416.2111 Conditions for our agreeing to make Medicaid eligibility determinations.

We will agree to make Medicaid eligibility determinations for a State only if the State's Medicaid eligibility requirements for recipients of SSI benefits and for recipients of State supplementary payments are the same as the requirements for receiving SSI benefits and the requirements for receiving State supplementary payments, respectively. Exceptions: We may agree to make Medicaid eligibility determinations— (a) For one, two, or all of the three categories of people (i.e., aged, blind, and disabled) who receive SSI benefits or State supplementary payments; or (b) Even though the State's Medicaid eligibility requirements for recipients of SSI benefits or of State supplementary payments, or both, differ from the requirements for SSI or State supplementary payments, or both, in ways mandated by Federal law.

20 C.F.R. § 416.2116 Medicaid eligibility determinations.

If a State requests, we may agree, under the conditions in this subpart, to make Medicaid eligibility determinations on behalf of the State. Under these agreements, we make the Medicaid determinations when determinations or redeterminations are necessary for SSI purposes. Our determinations may include non-SSI requirements that are mandated by Federal law. When we determine that a person is eligible for Medicaid in accordance with § 416.2111 or that we are not making the determination, we notify the State of that fact.

20 C.F.R. § 416.2130 Effect of the agreement and responsibilities of States.

(a) An agreement under this subpart does not change— (1) The provisions of a State's Medicaid plan; (2) The conditions under which the Secretary will approve a State's Medicaid plan; or (3) A State's responsibilities under the State Medicaid plan. (b) Following are examples of functions we will not agree to carry out for the State: (1) Stationing of our employees at hospitals or nursing homes to take Medicaid applications; (2) Determining whether a person is eligible for Medicaid for any period before he or she applied for SSI benefits; (3) Giving approval for emergency medical care under Medicaid before a determination has been made on whether a person is eligible for SSI benefits; (4) Setting up or running a State's system for requiring a person to pay part of the cost of services he or she receives under Medicaid; or (5) Giving identification cards to people to show that they are eligible for Medicaid.

20 C.F.R. § 416.2140 Liability for erroneous Medicaid eligibility determinations.

If the State suffers any financial loss, directly or indirectly, through using any information we provide under an agreement described in this subpart, we will not be responsible for that loss. However, if we erroneously tell a State that a person is eligible for Medicaid and the State therefore makes erroneous Medicaid payments, the State will be paid the Federal share of those payments under the Medicaid program as if they were correct.

20 C.F.R. § 416.2145 Services other than Medicaid determinations.

We will agree under authority of section 1106 of the Act and 31 U.S.C. 6505 to provide services other than Medicaid determinations to help the State administer its Medicaid program. We will do this only if we determine it is the most efficient and economical way to accomplish the State's purpose and does not interfere with administration of the SSI program. The services can be part of a Medicaid eligibility determination agreement or a separate agreement. Under either agreement we will— (a) Give the State basic information relevant to Medicaid eligibility from individuals' applications for SSI benefits; (b) Give the State answers to certain purely Medicaid-related questions (in addition to any that may be necessary under § 416.2111(b)), such as whether the SSI applicant has any unpaid medical expenses for the current month or the previous 3 calendar months; (c) Conduct statistical or other studies for the State; and (d) Provide other services the State and we agree on.

20 C.F.R. § 416.2161 Charges to States.

(a) States with Medicaid eligibility determination agreement. A State with which we have an agreement to make Medicaid eligibility determinations is charged in the following manner: (1) If making Medicaid determinations and providing basic SSI application information for a State causes us additional cost, the State must pay half of that additional cost. “Additional cost” in this section means cost in addition to costs we would have had anyway in administering the SSI program. (2) The State must pay half our additional cost caused by providing any information that we collect for Medicaid purposes and by any other services directly related to making Medicaid eligibility determinations. (3) The State must pay our full additional cost for statistical or other studies and any other services that are not directly related to making Medicaid eligibility determinations. (b) States without Medicaid eligibility determination agreement. A State with which we do not have an agreement to make Medicaid eligibility determinations is charged in the following manner: (1) If providing basic SSI application information causes us additional cost, the State must pay our full additional cost. (2) The State must pay our full additional cost caused by providing any information that we collect for Medicaid purposes and for statistical or other studies and any other services.

20 C.F.R. § 416.2166 Changing the agreement.

The State and we can agree in writing to change the agreement at any time.

20 C.F.R. § 416.2171 Duration of agreement.

An agreement under this subpart is automatically renewed for 1 year at the end of the term stated in the agreement and again at the end of each 1-year renewal term, unless— (a) The State and we agree in writing to end it at any time; (b) Either the State or we end it at any time without the other's consent by giving written notice at least 90 days before the end of a term, or 120 days before any other ending date selected by whoever wants to end the agreement; or (c)(1) The State fails to pay our costs as agreed; (2) We notify the State in writing, at least 30 days before the ending date we select, why we intend to end the agreement; and (3) The State does not give a good reason for keeping the agreement in force beyond the ending date we selected. If the State does provide a good reason, the termination will be postponed or the agreement will be kept in force until the end of the term.

20 C.F.R. § 416.2176 Disagreements between a State and us.

(a) If a State with which we have an agreement under this subpart and we are unable to agree about any question of performance under the agreement, the State may appeal the question to the Commissioner of Social Security. The Commissioner or his or her designee will, within 90 days after receiving the State's appeal, give the State either a written decision or a written explanation of why a decision cannot be made within 90 days, what is needed before a decision can be made, and when a decision is expected to be made. (b) The Commissioner's decision will be the final decision of the Social Security Administration.

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