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 individual1
- was simultaneously entitled to receive both social security (Old Age, Survivors, or Disability Insurance (OASDI)) and SSI in some month after April 1977;2
- 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;
- is currently ineligible for SSI; and
- is currently eligible for and receiving OASDI.
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. Ms. 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 $1,404 per month, which happens to be the average monthly benefit for retired workers. Her private pension is $300 a month, giving her a total of $1,704 monthly.
In 2018, the income limit for SSI (taking into account a $20 general income disregard) is $770 for an individual. Thus, Ms. 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.3
You screen Ms. 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 (.254). You multiply Ms. Gherkin’s current social security benefit of $1,404 by that factor, to determine her current countable “Pickle” income:
$1,404 multiplied by .254 = $356 (“Pickled” social security income, rounded downward)
$356 countable social security income + $300 private pension = $656 total countable “Pickle” income.
Since $656 is less than the current SSI income limit (including the standard $20 disregard) of $770, Ms. Gherkin is eligible for Medicaid, even though she is ineligible for SSI.
Pickle Meets the Affordable Care Act
Q. In a world with the Affordable Care Act, 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. At this time 18 states have not expanded 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 $16,000 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 an application to the health insurance marketplace supposed to result in the applicant being screened 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 Pickle eligibility is not one of the categories of Medicaid coverage for which the marketplace routinely screens applicants. Upon request, the marketplace will refer applicants to the state Medicaid agency for a more detailed screening that should include assessment of Pickle eligibility, but the applicant needs to know to request a referral for a full Medicaid assessment. And historically even seasoned state Medicaid eligibility programs have failed to identify most Pickle-eligible individuals who have sought Medicaid coverage. Applicants need to know that they are eligible for Medicaid under the Pickle Amendment and should appeal if they are found ineligible.
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 2018
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.
|If SSI was terminated during this period||Multiply 2018 OASDI income by4|
|July 1977–June 1978||.254|
|July 1978–June 1979||.270|
|July 1979–June 1980||.297|
|July 1980–June 1981||.339|
|July 1981–June 1982||.377|
|July 1982–Dec. 1983||.405|
|Jan. 1984–Dec. 1984||.420|
|Jan. 1985–Dec. 1985||.434|
|Jan. 1986–Dec. 1986||.448||Jan. 1987–Dec. 1987||.454|
|Jan. 1988–Dec. 1988||.473|
|Jan. 1989–Dec. 1989||.492|
|Jan. 1990–Dec. 1990||.515|
|Jan. 1991–Dec. 1991||.542|
|Jan. 1992–Dec. 1992||.562|
|Jan. 1993–Dec. 1993||.579|
|Jan. 1994–Dec. 1994||.594|
|Jan. 1995–Dec. 1995||.611|
|Jan. 1996–Dec. 1996||.627|
|Jan. 1997–Dec. 1997||.645|
|Jan. 1998–Dec. 1998||.659|
|Jan. 1999–Dec. 1999||.667|
|Jan. 2000–Dec. 2000||.684|
|Jan. 2001–Dec. 2001||.708|
|Jan. 2002–Dec. 2002||.726|
|Jan. 2003–Dec. 2003||.736|
|Jan. 2004–Dec. 2004||.752|
|Jan. 2005–Dec. 2005||.772|
|Jan. 2006–Dec. 2006||.804|
|Jan. 2007–Dec. 2007||.830|
|Jan. 2008–Dec. 2008||.849|
|Jan. 2009–Dec. 2011||.8995|
|Jan. 2012–Dec. 2012||.931|
|Jan. 2013–Dec. 2013||.947|
|Jan. 2014–Dec. 2014||.961|
|Jan. 2015–Dec. 2016||.9776|
|Jan. 2017–Dec. 2017||.980|
- In nine states, known as 209(b) states, Supplemental Security Income (SSI) eligibility does not automatically confer Medicaid eligibility: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, 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)).↑
- States may supplement SSI with additional payments of their own. All states except Arizona, Arkansas, Mississippi, Oregon, Tennessee, Texas, and West Virginia supplement the federal payment by amounts varying by state from $10 to about $700 (Elizabeth Dickey, Income and Asset Limits for SSI Disability Eligibility, NOLO (2017). But see U.S. Social Security Administration, Supplemental Security Income (SSI) Benefits (2017) (listing only Arizona, Mississippi, North Dakota, and West Virginia as states not paying an SSI supplement)). The SSI limit -- and therefore the Pickle Amendment limit -- in a given state is raised by the amount of that state's supplement, if any.↑
- 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).↑
- The cost of living did not increase for two years after 2008, and there was no social security cost-of-living adjustment in 2010 or 2011. The Pickle reduction factor is therefore the same for individuals who lost SSI in 2009–2011.↑
- The cost of living remained flat in 2015, so there was no social security cost-of-living adjustment in 2016.↑
This screening tool is posted here courtesy of the Tennessee Justice Center (a member of the Legal Impact Network) and the National Health Law Program.