Eligibility

Eligibility

How Incarceration Affects Eligibility

Complex rules affect eligibility for federal benefits when someone enters a correctional facility. Federal laws prohibit federal financial participation (FFP), also known as matching payments, to support benefits to individuals in state-run institutions, including correctional facilities and Institutions for Mental Disease (IMDs).[1]

While the federal statute bans FFP, it does not specify that states must terminate Medicaid benefit eligibility for individuals entering correctional facilities or IMDs. Yet, in practice, most states do terminate rather than suspend benefit eligibility for incarcerated individuals or terminate benefits after a certain period of time. A study conducted by the Council of State Governments in 2000 found that 46 states and two territories have policies that require termination of Medicaid supports for people in jail.[2]

Rules governing Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) eligibility when beneficiaries enter jail or prison are different than those that affect Medicaid. Benefits are not terminated when individuals enter a correctional facility and may never be terminated, depending on the length of stay in a correctional facility and type of conviction, among other factors. For a thorough discussion of the impact of incarceration on SSI/SSDI and Medicaid, please see the Council of State Governments Justice Center’s Criminal Justice/Mental Health Consensus Project Report, Appendix C.

Eligibility Criteria

Medicaid

The Centers for Medicaid & Medicare Services (CMS) outline certain “mandatory eligibility groups” to whom state agencies overseeing Medicaid must provide coverage to receive federal matching funds to operate the Medicaid program. Click here to view a list of mandatory eligibility groups, which includes disabled individuals. However, states may exercise some discretion in determining both documentation required to substantiate mandatory eligibility and income thresholds for receiving benefits.

Disability Eligibility and State Definitions

The policies and practices recommended in this tool are generally focused on individuals applying for coverage based on a disability due to serious mental illness. Disability under Medicaid, except in a handful of states, is defined according to the same guidelines that Social Security uses from Title XVI, sec. 1605, of the Social Security Act.[3]

In 32 states and the District of Columbia, known as “1634 states,” when individuals are deemed eligible for SSI, they are automatically deemed eligible for Medicaid.

In seven other states and one territory, known as “SSI criteria states,” eligibility criteria for SSI and Medicaid are the same; however, individuals must submit separate applications for SSI/SSDI and Medicaid to become eligible for both programs. These states include Alaska, Idaho, Kansas, Nebraska, Nevada, Oregon, Utah, and Northern Mariana Islands.

Both 1634 states and SSI criteria states use Title XVI disability criteria. A serious mental illness diagnosis that is linked to evidence of functional impairment and prevents a person from engaging in “substantial gainful activity,” or significant work, may be sufficient for some individuals to meet disability criteria. In some cases, individuals may need to demonstrate an inability to engage in substantial gainful activity by presenting evidence of mental illness in combination with other common nondisabling, nonterminal conditions (e.g., certain types of diabetes, asthma, and heart disease). As previously noted, this tool focuses on policies related to applicants with serious mental illnesses. However, individuals with impairments other than serious mental illnesses, such as various types of physical disabilities, may be eligible for SSI/SSDI. Click here for more information on these impairments.

Finally, in 11 states, known as “209b” states, people who receive SSI nearly always qualify for Medicaid; however applications and eligibility criteria for Medicaid and SSI are different. These states are Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia. Some of the state Medicaid programs use different eligibility criteria related to substantiating disabilities, and some use different resource criteria than SSI/SSDI programs.[4]

SSI/SSDI

To be eligible for SSI, individuals must be 65 or over, blind, or have a disability. In addition, applicants must demonstrate that they have limited income and limited resources and have applied for all other cash benefits for which they may be eligible (e.g., Temporary Assistance for Needy Families [TANF]). To view a full list of SSI eligibility criteria, click here.

To qualify for SSDI, an applicant must demonstrate that he or she has a disability or is blind and has paid federal insurance contributions (FICA) tax on income for a certain period of time, depending on age. In addition, some individuals may qualify for a type of SSDI based on parents’ earnings under the disabled adult child (DAC) benefit. To view a full list of SSDI eligibility criteria, click here.

Disability Definition

The Social Security Administration defines disability according to Title XVI, sec. 1605, of the Social Security Act.[5] To meet this definition, applicants must show that the impairment they experience is tied to a medical condition and results in an inability to engage in any substantial gainful activity. Further, applicants must demonstrate that the condition is either expected to result in death or is expected to last for a continuous period of not less than 12 months.[6]

Co-occurring Disorders

As of January 1, 1997, individuals who had received SSI and/or SSDI based on a substance use disorder that was deemed material or contributory to their disability, lost their SSI/SSDI eligibility and had to reapply to maintain benefits. This action was taken after the enactment of Public Law 104-121[7]; subsequent to this legislation, individuals with substance use disorders and another or multiple disabilities that prevent substantial gainful activity can still be eligible for SSI/SSDI so long as the substance use disorder is not presented as evidence of disability in applications.


[1] FFP may be allowed for specific services provided to IMD residents under age 21 or, in some cases, under age 22 or age 65 years and older. (see Draper DA, McHugh MC, Achman L, Kuo S. Medicaid Financing of State and County Psychiatric Hospitals. DHHS Pub. No. (SMA) 03-3830 Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003.)

[2] C. Brown, “Jailing the Mentally Ill,” State Government News, April 2001, 28. In addition, while state policies may require termination of Medicaid upon incarceration, in practice, eligibility may not be terminated until the state Medicaid agency is made aware of the incarceration at a later date or an individual who is incarcerated does not file a necessary continuation with the state agency.

[3] http://www.ssa.gov/OP_Home/ssact/title16a/1605.htm

[4] For further reading on different eligibility criteria used by 209(b) states, see “A Word About States and Medicaid” and “A Primer on How to Use Medicaid to Assist Persons Who are Homeless to Access Medical, Behavioral Health, and Support Services” (scroll to section “State 209(b) option”).

[5] http://www.ssa.gov/OP_Home/ssact/title16a/1605.htm

[6] Ibid.

[7] Sec. 105 of this law amended the Title II disability definition used by Social Security: “An individual shall not be considered to be disabled for purposes of this title if alcoholism or drug addiction would (but for this subparagraph) be a contributing factor material to the Commissioner’s determination that the individual is disabled.’’ http://www.gpoaccess.gov/plaws/search.html