WAC 182-508-0015 Determining if an individual is incapacitated.

When an individual applies for medical care services (MCS) program benefits, the individual must provide medical evidence to the agency or the agency's designee that shows the individual is unable to work.

If an individual is gainfully employed at the time of application for MCS, the agency or the agency's designee denies incapacity.  "Gainful employment" means an individual is performing, in a regular and predictable manner, an activity usually done for pay or profit and earning more than the substantial gainful activity standard as defined by the Social Security Administration.

(1)  The agency or the agency's designee doesn't consider work to be gainful employment when the individual is working:

(a)  Under special conditions that go beyond the employer providing reasonable accommodation, such as in a sheltered workshop the agency or the agency's designee has approved; or

(b)  Occasionally or part-time because the individual's impairment limits the hours the individual is able to work compared to unimpaired workers in the same job.

(2)  The agency or the agency's designee determines if the individual is incapacitated when the individual:

(a)  Applies for medical benefits:

(b)  Becomes employed;

(c)  Obtains work skills by completing a training program; or

(d)  The agency or the agency's designee receives new information that indicates the individual may be employable.

(3)  Unless the individual meets the other incapacity criteria in WAC 182-508-0010, the agency or the agency's designee decides incapacity by applying the progressive evaluation process (PEP) to the medical evidence that the individual provides that meets WAC 182-508-0030.  The PEP is the sequence of eight steps described in WAC 182-508-0035 through 182-508-0110.

(4)  If the individual has a physical or mental impairment and the individual is impaired by alcohol or drug addiction and does not meet the other incapacity criteria in WAC 182-508-0010, the agency or the agency's designee decides if the individual is eligible for MCS by applying the PEP described in WAC 182-508-0035 through 182-508-0110.  The individual isn't eligible for MCS benefits if the individual is incapacitated primarily because of alcoholism or drug addiction.

(5)  In determining incapacity, the agency or the agency's designee considers only the individual's ability to perform basic work-related activities.  "Basic work-related activities" are activities that anyone would be required to perform in a work setting.  They consist of:  sitting, standing, walking, lifting, carrying, handling; and other physical functions (including manipulative or postural functions such as pushing, pulling, reaching, handling, stooping, or crouching), seeing, hearing, communicating, and understanding and following instructions, responding appropriately to supervisors and co-workers, tolerating the pressures of a work setting, maintaining appropriate behavior, and adapting to changes in a routine work setting.