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Medicaid & MSP: Must apply for Social Security and Enroll in Medicare

Medicaid applicants and recipients can be required to pursue potentially available income as a condition of receiving Medicaid, and also to apply for Medicare.  (42 CFR 435.608; 18 NYCRR sec. 360-2.3 (c)(1); Medical Assistance Resource Guide [MARG] pp. 488-489.)  

1.    Must apply for Medicare - New requirements November 2017

In Oct. 2017, NYS DOH issued 17 OHIP ADM-01:  "Medicare Enrollment at Age 65" (PDF) (Click here for html version and attachments).  This ADM further implements NY Social Services Law  Sec.366(2)(b)(1) which states: "Any person who is eligible for, or reasonably appears to meet the criteria of eligibility for, benefits under title XVIII of the federal social security act [Medicare] shall be required to apply for and fully utilize such benefits in accordance with this chapter."  Also see NYS DOH Medicaid Reference Guide (MRG) page 415.

The ADM requires for the first time certain Medicaid applicants and beneficiaries to submit proof that they applied to enroll in Medicare -  for new applicants at the time of application, or at the time of renewal, for current recipients.  New applicants and people receiving renewals in NYC will receive this insert in their application or renewal package

In December 2017, NYC HRA issued this Medicaid Alert implementing the State ADM in NYC. 

In December 2017, letters are going out to 30,000 NYS Medicaid recipients over age 65 (half of which are in NYC) telling them they must enroll in Medicare to keep Medicaid, and must return proof of application for or enrollment in Medicare to their local Dept. of Social Services.   NYC HRA is mailing letters to 15,000 NYC residents in batches, with the first sent to 6000 people on Dec. 15, 2017. Their response is due Jan. 15, 2018.   A sample notice is on page 3 of this Tip Sheet by the Medicare Rights Center.    

MAY REQUEST EXTENSIONS - Consumers may request an extension (by phone in upstate counties) and (by mail/phone in NYC).   In NYC, certified "C-Rep" representatives may submit MAP 3062(c) Request for Extension to the Undercare Processing Division.   Or consumers or their reps may call Medicaid Helpline  1-888-692-6116.   A failure to respond on time or ask for an extension before the due date will result in HRA/DSS issuing a Notice of intent to discontinue Medicaid coverage. 

Who is receiving the Notices?  The notices are being mailed to Medicaid recipients who are:

  1. age 65+  and 

  2. Do not have Medicare Part A or Part B (which means they likely do not receive Social Security benefits, since Medicare is automatic for people age 65+ receiving Social Security),

  3. Are US Citizens or have been Permanent Resident Aliens for 5+ years

  4. Have incomes below the Medicare Savings Program SLIMB level  (120% Federal Poverty Level)
    ($1226  singles /  $1644 couple)

WARNING -- These 30,000 Medicaid recipients risk  having their Medicaid discontinued in December 2017 or later if they do not return proof that they applied for Medicare to the Local Dept. of Social Services.  The deadline for the first 6000 NYC residents who received a letter sent Dec. 15, 2017 is Jan. 15, 2018.  If they applied for Medicare but were not enrolled they should be given an extension.  Since discontinuance of Medicaid can have serious consequences, including termination of home care, ask for a Fair Hearing right away if you did not receive an advance Notice of discontinuance or if there was an error.    Get help from your local legal services program - see www.lawhelpNY.org or call the Medicare Rights Center at 1-800-333-4114. 

The Medicare Rights Center created a Tip Sheet which explains this enrollment effort and provides helpful information on Medicare enrollment for those with Medicaid and no parts of Medicare.  The Tip Sheet explains how they can enroll in Medicare without having to pay a premium.   

  • Some recipients can enroll in premium-free Medicare Part A and Part B -- these are those who are Qualified Medicare Beneficiiaries, (QMB) with incomes under 100% FPL.   See  MRC fact sheet on how to enroll in free Medicare Part A through the  "Part A Buy-In Program."   Also see the SSA POMS on QMBs and Part A. 

  • Others do not qualify for free Part A, but can enroll in Part B without a premium.  These are SLIMB's - a Medicare Savings Program for people whose income is between 100 FPL - 120% FPL.  

  • Clients going to the SSA to apply for Medicare should bring the notice from DSS/HRA requiring them to apply, and bring the Medicare Rights Center Tip Sheet to help explain to the SSA why they are applying for Medicare.  Don't forget they need only APPLY for Medicare - and show proof that they applied to HRA/DSS.  

​Recommended Follow-Up for Consumers Newly Enrolled in Medicare:

Consumers newly enrolled in Medicare may need additional help with the transition:

  •        counseling on their Medicare Part D (prescription drug) coverage options - help select a plan that covers all of her drugs, rather than wait to be auto-assigned randomly to a plan that may not cover her drugs;  also see Part D info

  •        if client was in a Medicaid "mainstream" managed care plan, she will now be disenrolled from that plan once she has Medicare.  She will need counseling on whether to enroll in a Medicare Advantage plan or whether to use Original Medicare and enroll in a Part D plan; and

  •        For those consumers who received Medicaid home care through a Medicaid  managed care plan (MCO), ensure they are transferred from their Managed care plan to an MLTC plan without a disruption in their personal care services. 

  •    See Medicare Rights Center info for people new to Medicare

2.  Must apply for Social Security and other "Potentially available income"

This means entitlement benefits like annuities, pensions, retirement and disability benefits, veterans benefits and unemployment compensation.  It does NOT include cash support. (MARG p. 561; 99 ADM-05)

The NYS Department of Health recently clarified in  GIS 13 MA/005 - Buy-In for Individuals with Medicare who have not applied for Social Security Retirement Benefits  [PDF] that this requirement to pursue potentially available income applies to Medicare Savings Program (MSP) applicants/recipients who are eligible for Social Security retirement benefits.  These individuals cannot delay enrollment in Social Security and still qualify for MSP.   This rule affects some people who would otherwise prefer to delay receipt of Social Security until after age 66 since the amount of the benefit increases for every year of delay until age 70.   But one doesn't have that option if one wants Medicaid or an MSP.  

EXCEPTION announced Oct. 2016:  If the client is working full-time, they do NOT have to apply for Social Security benefits at age 62 or later. This was announced in GIS 16 MA/012, "Applying for Entitlement Benefits," which states, "When an A/R is still working full time, districts must not require the A/R to apply for Social Security Retirement benefits."

Enrolling in a pooled supplemental needs trust is an option to reduce countable income to qualify for Medicaid and/or MSP (re MSP see See Fair Hearing No. 4399513P (Nassau Co., Jan. 31, 2006)(available in WNYLC Online Resource Center, Fair Hearing Database, free registration required) .


This article was authored by the Empire Justice Center and New York Legal Assistance Group.  

Empire Justice Center


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