Access to Medicaid Expenditure Records for SSA’s 1619(b) Individualized Threshold Development

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A barrier to establishing an individualized threshold under Social Security’s Supplemental Security Income (SSI) program has been access to an accurate estimation of an individual’s Medicaid expenditures. Disability Rights Florida has collaborated with the Agency for Health Care Administration (AHCA) to establish two different reports that can be accessed by either the individual or a third-party helping the individual to show the paid claims for the determination period and a monthly breakdown to expedite SSA processing.

When an SSI beneficiary is no longer receiving a cash benefit due to work, they can utilize the 1619(b) work incentive in order to keep their Medicaid. One of the rules to be eligible for this work incentive is that the beneficiary does not earn more than the state threshold amount for that year based on the state that they live in. Here is where you can find the State’s threshold formula and current threshold amounts.

What if I earn over the state threshold?

When an individual who is otherwise eligible for 1619(b) has gross earnings, which exceed the amount of their state’s threshold, a different calculation may be made to see if an individualized threshold may keep them eligible for Medicaid. Social Security will look at the annual amount of any (1) Impairment Related Work Expenses (IRWE), (2) Blind Work Expenses (BWE), (3) income excluded under an approved PASS, (4) the value of any publicly funded attendant care*, and (5) the individual’s estimated Medicaid expenditure for the determination period to see if a higher individualized threshold may be established.

The new AHCA report was established to help an individual have proper documentation to support number (5) of the individualized threshold calculation.

AHCA has also updated their Authorization for the Use and Disclosure of Protected Health Information (AHCA Form 1000-3003, Revised (FEB 2018)) to make it more user-friendly to request these types of reports. An individual may request the reports themselves without a third-party by using AHCA Form 1000-3005.

 

* per Social Security's Program Operating Manual SI 02302.050D.3, which in part states, "that services were funded in whole or in part by federal, state, or local funds other than Medicaid" Please see this entire section if utilizing this expenditure.

How do I request a report?

When requesting a report from AHCA:

Individuals using AHCA Form 1000-3005 will need to do the following

  • Mark the checkbox for “Paid Claims” 
  • Mark the checkbox for “Other” and write, “full report and monthly report” in the space provided 
  • Include the specific dates of service (which would be the determination period given by Social Security and is usually at minimum 12 months), 
  • Include name, SSN, Medicaid ID or gold card number, phone number, date of birth, address, city, state, ZIP Code and signature at the bottom. 

Third-parties using AHCA Form 1000-3003, revised (FEB 2018) will need to do the following 

  • Mark the checkbox for “Paid Claims Records” 
  • Include the specific dates of service (which would be the determination period given by Social Security and is usually at minimum 12 months),  
  • Under “purpose for this disclosure,” write “full report and monthly report” in the space provided (This should be before any other note in this section.) 
  • Include the individual’s name, SSN, Medicaid ID or gold card number, phone number, date of birth, address, city, state, ZIP Code and signature of the individual at the bottom. 
     

How do I get a copy of the release forms for AHCA?

You may get a copy of either of the aforementioned release forms on AHCA’s website.