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DocuSign Envelope ID: 3289A281-EC13-40C5-A56D-BE1F23756321 North Carolina Department of Health and Human Services AGED, BLIND AND DISABLED MEDICAID MANUAL MA-1000 14

SSI MEDICAID – AUTOMATED PROCESS

(VII.D.1.) b. If the recipient does not appeal the SSI termination timely, the recipient is no longer considered disabled and is ineligible for MAD when: (1) He ceases to pursue the SSI appeal up to the appeals council,

(2) SSA doesn’t accept the appeal for a good cause reason.

2. Begin the process by evaluating eligibility in all coverage groups. Use all agency verifications to determine eligibility before contacting the a/r. Use the DMA-5180, SSI Check Terminated: Information Needed to Determine Medicaid Eligibility, to contact the a/r. If additional information is needed, use the DMA-5097, Request for Information. a. If the recipient remains eligible in another category, immediately transfer the case to that aid program category.

b. The county must complete the ex-parte review process in four months. The four months begin the month the case appears on the SSI termination report.

c. If the recipient is not eligible in another category, terminate the case after timely notice.

3. If the recipient appeals the county’s decision to terminate the case and recipient alleges he is still disabled, request a state hearing. The State Hearing Officer determines if the recipient meets one of the conditions in a., b., or c.

a. Has a disabling condition different from, or in addition to the conditions considered in the original SSA disability decision, or

b. Alleges more than 12 months after the most recent SSA termination for not being disabled that his condition has changed or deteriorated and his period of disability meets the 12 month durational requirement, and he has not reapplied at SSA based on those new allegations, or

c. Alleges less than 12 months after the most recent SSA termination for not being disabled, that his condition has changed or deteriorated, and his period of disability meets the 12 month durational requirement, and

(1) He has applied to SSA for reconsideration or reopening and SSA refuses to consider the changes, and /or

(2) He does not meet other SSI eligibility requirements e.g., reserve, but may meet the state’s Medicaid eligibility requirements for MAD.

4. If the State Hearing Officer determines that a., b., or c. applies, then the State Hearing Officer will determine if the recipient meets the disability requirements. If the Hearing Officer determines the recipient is still disabled, MAD is continued or reinstated.