Academic journal article Social Security Bulletin

State Medicaid Eligibility and Enrollment Policies and Rates of Medicaid Participation among Disabled Supppplemental Security Income Recipients

Academic journal article Social Security Bulletin

State Medicaid Eligibility and Enrollment Policies and Rates of Medicaid Participation among Disabled Supppplemental Security Income Recipients

Article excerpt

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The Supplemental Security Income (SSI) program is a crucial component of the social safety net for low-income adults with severe disabilities. In addition to providing federal cash payments (with optional state supplements), SSI often serves as a gateway to health insurance under Medicaid. Although SSI and Medicaid are both means-tested programs, financial eligibility for SSI is determined using standard national criteria, whereas Medicaid is administered by the states, which have considerable leeway in developing Medicaid eligibility policies. In 40 states and the District of Columbia (41 jurisdictions), SSI awardees are categorically eligible for Medicaid. In 34 of those jurisdictions, the Social Security Administration (SSA) promptly notifies the state Medicaid agency of an individual's categorical eligibility for Medicaid upon award of SSI payments using an electronic transmission process-in other words, Medicaid enrollment is automatic.1 However, in seven of the states where SSI eligibility confers Medicaid eligibility, SSI awardees must file a separate Medicaid application.2 Ten other states also require a separate Medicaid application and employ Medicaid income or asset limits that are more restrictive than those for SSI, with the result that some SSI recipients do not qualify for Medicaid coverage in those states.3 Thus, we observe three distinct state Medicaid enrollment policy regimes for SSI awardees:

1. automatic Medicaid enrollment of SSI awardees, initiated by SSA, and categorical Medicaid eligibility using uniform national standards to establish SSI eligibility for federal benefits (hereafter, automatic enrollment);

2. the requirement of a separate Medicaid application and the reliance on SSA's determination of SSI eligibility to establish categorical Medicaid eligibility (hereafter, separate-application/nonrestrictive); and

3. the requirement of a separate Medicaid application with Medicaid eligibility criteria that are more restrictive than those for SSI (hereafter, separate-application/restrictive).

Box 1 summarizes the policy regimes and lists the states that have adopted them.

Requiring a separate Medicaid application may limit Medicaid enrollment among SSI recipients for several reasons. First, it imposes a burden of additional time and effort on the applicant. Recent evidence from behavioral economics suggests that default automatic enrollment substantially increases participation (Knoll 2010). Second, requiring a separate application increases administrative complexity, which may result in processing delays and an extended period of uncertainty about ultimate eligibility for Medicaid coverage. Further, the Medicaid enrollment rates of SSI recipients in separate application/restrictive states are expected by design to be lower than those in other states, at least initially. However, automatic enrollment does not necessarily guarantee swift access to Medicaid coverage because it does not take place until after SSA determines that an SSI applicant meets the program's definition of disability, which may require more than one level of adjudication; in some cases, that process may take more than 2 years. For these and other reasons, we are particularly interested in both temporary and long-term effects of automatic enrollment on Medicaid coverage, as compared with the separate-application policy regimes.

This study examines month-to-month longitudinal dynamics of Medicaid coverage among disabled adult first-time SSI awardees who do not receive any Social Security Disability Insurance (DI) benefits. We track Medicaid coverage not only for 72 months starting with the month of SSI award but also for the 12 months prior to eligibility onset. Throughout the article, "Medicaid coverage" applies to individuals who are eligible for full Medicaid benefits and excludes those who receive only partial benefits under Medicare Savings Programs (such as the Qualified Medicare Beneficiary and the Specified Low Income Beneficiary programs). …

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