A Quick and Easy Method of Screening for Medicaid Eligibility Under the Pickle Amendment: Still Relevant After the Affordable Care Act
By Gordon Bonnyman, Executive Director, Tennessee Justice Center
The Pickle Amendment, named after its congressional sponsor and enacted in 1977, requires that an individual is to be deemed a Supplemental Security Income (SSI) recipient (which in most states means automatic Medicaid eligibility) if the individual/1/
- was simultaneously entitled to receive both social security (Old Age, Survivors, or Disability Insurance (OASDI)) and SSI in some month after April 1977;/2/
- is currently eligible for and receiving OASDI;
- is currently ineligible for SSI; and
- receives income that would qualify the individual for SSI after deducting all OASDI cost-of-living adjustments (COLA) received since the last month in which the individual was eligible for both OASDI and SSI.
Screening for Medicaid eligibility under the Pickle Amendment is quick and simple. Without the necessity of performing any mathematical calculations, screening eliminates the great majority of those who are not eligible. For those who survive the initial screening and for whom mathematical calculations are required, the table below shows a simple formula for performing the necessary calculations.
Screening is as follows:
Step 1. Ask the individual, “Are you now receiving a social security check?” If the answer is no, the individual is not Pickle eligible. If the answer is yes, go on to step 2.
Step 2. Ask the individual, “After April 1977, did you ever get an SSI check at the same time that you got social security, or did you get SSI in the month just before your social security started?” If the answer is no, the individual is not Pickle eligible. If the answer is yes, go on to step 3.
Step 3. Ask the individual, “What is the last month in which you received SSI?”
Step 4. Look up, in the table below, the month in which the individual last received SSI. Find the percentage that applies to that month. Multiply the present amount of the individual’s (and/or spouse’s) social security (OASDI) benefits by the applicable percentage.
Step 5. You have just calculated the individual’s countable social security income under the Pickle Amendment. Add the figure that you have just calculated to any other countable income the individual may have. If the resulting total is less than the current SSI income criteria in your state, the individual is Pickle eligible, from the standpoint of income, for Medicaid benefits. (The individual must still satisfy separate Medicaid resource and nonfinancial requirements.)
Example. Mrs. Ima Gherkin received both social security and SSI checks in 1976–78. However, her SSI was terminated in March 1978 because she started receiving a private pension that, added to her social security benefits, raised her income to an amount above the 1978 SSI income limits. There have been gradual increases in her income since 1978. She now receives a social security benefit of $1,294 per month, which happens to be the average monthly benefit for retired workers. Her private pension is $275 a month, giving her a total of $1,569 monthly.
In 2014 the income limit for SSI (taking into account a $20 general income disregard) is $741 for an individual. Thus, Mrs. Gherkin’s income is over twice the SSI income limit, which her state has adopted as the Medicaid limit for individuals who are aged, blind, or disabled.
You screen Mrs. Gherkin for Pickle eligibility as outlined above. Determining that the last month in which she received both social security and SSI was March 1978, you look up that time period in the table below and find the corresponding reduction factor (.264). You multiply Mrs. Gherkin’s current social security benefit of $1,294 by that factor, to determine her current countable “Pickle” income: $1,261 multiplied by .264 = $341 (“Pickled” social security income, rounded downward); $341 countable social security income + $275 private pension = $616 total countable “Pickle” income. Since $616 is less than the current SSI income limit (including the standard $20 disregard) of $741, Mrs. Gherkin is eligible for Medicaid, even though she is ineligible for SSI.
Pickle meets Obamacare
Q. In an Obamacare world, who needs Pickle?
A. Lots of people.
With the implementation of the Affordable Care Act in January 2014, you may wonder why you should continue to screen people for potential Pickle eligibility. The Affordable Care Act improves access to affordable health coverage for millions of uninsured Americans, so you might assume that Pickle is no longer needed. In fact, however, Pickle remains important because: ( 1) Pickle is the only source of health coverage for many people, and (2) Pickle can lower medical expenses for many others.
Remember that Pickle eligibility requires that a person currently receive social security (OASDI) benefits. For that reason, potential Pickle eligibles include many people over 65, a group that does not qualify for the expanded Medicaid coverage offered under the Affordable Care Act. Nor can a person who has Medicare coverage, as most people over 65 do, qualify to receive a premium tax credit with which to buy commercial coverage. Qualifying the elderly for Medicaid through the Pickle Amendment can give them, in effect, a free Medicare supplement policy that is superior to almost any commercial Medicare supplement insurance.
The other major group of potential “Pickle people” is nonelderly adults with disabilities. Unlike those over 65, some may qualify for the Affordable Care Act’s expanded Medicaid coverage or for premium tax credits to defray the cost of commercial insurance. But even this group may find the new coverage promised by the Affordable Care Act to be out of reach. More than 25 states have refused to expand Medicaid coverage to nonelderly adults with incomes below 133 percent of the federal poverty level. Uninsured poor people living in one of those states will remain without Medicaid unless they can access the program through an existing category of Medicaid eligibility, such as Pickle. Pickle coverage is particularly important for those who have no coverage at all, a group that typically includes social security disability beneficiaries who have not completed the two-year waiting period for Medicare to begin. For them, Pickle can literally be a lifesaver.
Even in states that have expanded Medicaid and even for those who are relatively well off, Pickle remains important. The expansion raises income eligibility levels only to 133 percent of the federal poverty level (about $15,000 annually for a single person), while Pickle eligibility can potentially cover people with incomes substantially higher than that.
Those with incomes above the federal poverty level who lack insurance because they have yet to complete Medicare’s two-year waiting period could qualify for a premium tax credit with which to buy commercial insurance. But even they are likely to find that the Medicaid coverage available through the Pickle Amendment is more affordable and offers more generous benefits than subsidized commercial coverage under the Affordable Care Act.
Bottom line: keep screening for Pickle eligibility.
Q. But isn’t the health insurance marketplace supposed to screen for all sources of Medicaid eligibility? Can’t I just refer people to the marketplace and let it screen them?
A. Unless someone else flags them as eligible, the marketplace will probably overlook the Medicaid eligibility of most “Pickle people.”
Everyone who applies for coverage or a premium tax credit through the health insurance marketplace must be screened for potential Medicaid eligibility and determined to be ineligible for Medicaid before qualifying for a premium tax credit. But the marketplace will consider Pickle eligibility only if the individual makes a point of raising it. And historically even seasoned state Medicaid eligibility programs have failed to identify most Pickle-eligible individuals who have sought Medicaid coverage.
The Pickle population includes many medically, socially, and financially vulnerable individuals, for whom Medicaid coverage can make an enormous difference. These individuals are unlikely to enroll unless you identify and assist them.
Reduction Factors for Calculating Medicaid Eligibility Under the Pickle Amendment During 2014
If the last month an individual received SSI while, or immediately prior to, receiving social security (OASDI) was in any of the periods below, multiply the present amount of the individual’s social security by the corresponding factor.
Multiply 2014 OASDI income by/3/
July 1977–June 1978
July 1978–June 1979
July 1979–June 1980
July 1980–June 1981
July 1981–June 1982
July 1982–Dec. 1983
Jan. 1984–Dec. 1984
Jan. 1985–Dec. 1985
Jan. 1986–Dec. 1986
Jan. 1987–Dec. 1987
Jan. 1988–Dec. 1988
Jan. 1989–Dec. 1989
Jan. 1990–Dec. 1990
Jan. 1991–Dec. 1991
Jan. 1992–Dec. 1992
Jan. 1993–Dec. 1993
Jan. 1994–Dec. 1994
Jan. 1995–Dec. 1995
Jan. 1996–Dec. 1996
Jan. 1997–Dec. 1997
Jan. 1998–Dec. 1998
Jan. 1999–Dec. 1999
Jan. 2000–Dec. 2000
Jan. 2001–Dec. 2001
Jan. 2002–Dec. 2002
Jan. 2003–Dec. 2003
Jan. 2004–Dec. 2004
Jan. 2005–Dec. 2005
Jan. 2006–Dec. 2006
Jan. 2007–Dec. 2007
Jan. 2008–Dec. 2008
Jan. 2009–Dec. 2011
Jan. 2012–Dec. 2012
Jan. 2013-Dec. 2013
In eleven states, known as 209(b) states, Supplemental Security Income (SSI) eligibility does not automatically confer Medicaid eligibility: Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma, and Virginia (see Noland v. Shalala, 12 F.3d 258 (D.C. Cir. 1994)).
The individual need not literally receive both SSI and Old Age, Survivors, or Disability Insurance (OASDI) checks in the same month but need only be entitled to both for the same month. There is a one-month lag in OASDI payments, which are not disbursed until the month after entitlement, while SSI payments are paid in the month of entitlement. An individual commonly receives SSI while awaiting OASDI payments. Once the individual’s monthly OASDI begins, if it exceeds the SSI rate, the individual receives just OASDI thereafter. In such circumstances, even though the individual never actually received simultaneous payments from both programs in a single month, the individual meets the first Pickle requirement. This is true even if income from a retroactive OASDI payment exceeds the SSI benefit level for all months in which SSI was received. For this reason, you should ask not just if the individual received both SSI and OASDI in the same month but also if the individual received SSI immediately before the individual’s OASDI payments began (see 42 C.F.R. § 435.135 and 51 Fed. Reg. 12326 (April 10, 1986); for more information, see my Medicaid Eligibility in a Time Warp, 22 Clearinghouse Review 120 (June 1988)).
Due to social security’s rounding rules, the adjustment factors in the table produce an approximate, rather than exact, figure. Because a discrepancy of one cent may mean the difference between Medicaid eligibility as a Pickle case and inadequate access to health care, advocates should obtain exact information from the Social Security Administration if the figure produced by the screening method results in a determination that the individual is over the eligibility limit by a small amount (i.e., $20 or less).