Incapacity and Disability
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Incapacity and Disability


Revised December 31, 2013



Purpose: A person must be unable to work due to a mental or physical impairment to meet incapacity or disability criteria for ABD cash or a referral to the HEN program.

WAC 388-447-0001What are the incapacity requirements for referral to the Housing and Essential Needs (HEN) program?
WAC 388-449-0001What are the disability requirements for the Aged, Blind or Disabled (ABD) program?

WAC 388-449-0001

WAC 388-449-0001

Effective June 1, 2012

WAC 388-449-0001 What are the disability requirements for the Aged, Blind or Disabled (ABD) program?

  1. For the purposes of this chapter, the following definitions apply:
    1. "We" and "us" refer to the department of social and health services.
    2. "You" means the applicant or recipient.
    3. “Disabled”   means the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which has lasted or can be expected to last for a continuous period of not less than nine months with available treatment or result in death.
    4. "Physical impairment" means a diagnosable physical illness.
    5. "Mental impairment" means a diagnosable mental disorder. We exclude any diagnosis of or related to alcohol or drug abuse or addiction.
  2. We determine if you are likely to be disabled when:
    1. You apply for ABD cash benefits;
    2. You become employed;
    3. You obtain work skills by completing a training program; or
    4. We receive new information that indicates you may be employable.
  3. We determine you are likely to be disabled if:
    1. You are determined to meet SSA disability criteria by the Social Security Administration (SSA);
    2. You are determined to meet SSA disability criteria by Disability Determination Services (DDDS) based on the most recent DDDS determination;
    3. The Social Security Administration (SSA) stops your Supplemental Security Income (SSI) payments solely because you are not a citizen;
    4. You are eligible for long-term care services from aging and long-term support administration for a medical condition that is expected to last nine months or more or result in death; or
    5. You are approved through the Sequential Evaluation Process (SEP) defined in WAC 388-449-0005  through 388-449-0100. The SEP is the sequence of five steps. Step 1 considers whether you are currently working. Steps 2 and 3 consider medical evidence and whether you are likely to meet a listed impairment under Social Security’s rules. Steps 4 and 5 consider your residual functional capacity and vocational factors such as age, education, and work experience in order to determine your ability to do your past work or other work.
  4. If you have a physical or mental impairment and you are impaired by alcohol or drug addiction and do not meet the other disability criteria in subsection (2) (a) through (d) above, we decide if you are eligible for ABD cash by applying the sequential evaluation process described in WAC 388-449-0005 through WAC 388-449-0100. You aren't eligible for ABD cash benefits if you are disabled primarily because of alcoholism or drug addiction.
  5. In determining disability, we consider only your 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, remembering, understanding and following instructions, responding appropriately to supervision and coworkers, tolerating the pressures of a work setting, maintaining appropriate behavior, and adapting to changes in a routine work setting.
  6. We determine you are not likely to meet SSI disability criteria if SSA has denied your application for SSI or Social Security Disability Insurance (SSDI) based on disability in the last twelve months unless:
    1. You file a timely appeal with SSA;
    2. SSA decides you have good cause for a late appeal; or
    3. You give us medical evidence of a  potentially disabling condition that SSA did not consider  or medical evidence confirming your condition has deteriorated.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 388-447-0001

WAC 388-447-0001

Effective January 1, 2014

WAC 388-447-0001 What are the incapacity requirements for referral to the Housing and Essential Needs (HEN) program?

(1) For the purposes of this chapter, the following definitions apply:

(a) "We" and "us" mean the department of social and health ser-vices.

(b) "You" means the applicant or recipient.

(c) "Incapacitated" means you cannot be gainfully employed due to a physical or mental impairment that is expected to continue for at least ninety days from the date you apply.

(d) "Mental impairment" means a diagnosable mental disorder.

(e) "Physical impairment" means a diagnosable physical illness.

(2) You must be incapacitated in order to receive a HEN referral.

(3) We determine if you are incapacitated when:

(a) You apply for a referral to the HEN program;

(b) You become gainfully employed;

(c) You obtain work skills by completing a training program;

(d) We receive new information that indicates you may be able to work; or

(e) Your incapacity authorization period ends.

(4) We deny your HEN referral if you are gainfully employed at the time of application for referral to the HEN program. "Gainfully employed" means you are performing, in a regular predictable manner, an activity usually done for pay or profit and earning more than the substantial gainful activity standard defined by the social security administration (SSA).

(5) We do not consider you to be gainfully employed if you are working:

(a) Under special conditions that go beyond providing reasonable accommodation; or

(b) Occasionally or part-time because your impairment limits the hours you are able to work compared to unimpaired workers in the same job.

(6) We determine you are incapacitated if you are:

(a) Approved through the progressive evaluation process (PEP). The PEP is a sequence of eight steps described in WAC 388-447-0030 through 388-447-0100;

(b) Eligible for services from the developmental disabilities administration (DDA);

(c) Diagnosed as having an intellectual disability based on a full scale score of seventy or lower on the Wechsler adult intelli-gence scale (WAIS);

(d) Eligible for long-term care services from aging and long-term support administration (ALTSA);

(e) Released from a medical institution where you received ser-vices from ALTSA within the past 90 days; or

(f) Released from inpatient treatment for a mental impairment within the past 90 days if:

(i) The release from inpatient treatment was not against medical advice; and

(ii) You were discharged into outpatient mental health treatment.

(7) If you have a physical or mental impairment, are impaired by alcohol or drug addiction, and do not meet the other incapacity criteria in section 6 (b) through (f), we decide if you are incapacitated by applying the PEP. We do not consider symptoms related to substance use or a diagnosis of chemical dependency when determining incapacity when we have evidence substance use is material to your impairment(s).

(8) We consider substance use material to your impairment(s) if you are disabled primarily because of drug or alcohol addiction.

(9) If your impairment will persist at least sixty days after you stop using drugs or alcohol, we do not consider substance use to be material to your impairment(s).

(10) In determining incapacity, we consider only your 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, remembering, understanding and following instructions, responding appropriately to supervisors and co-workers, tolerating the pressures of a work setting, maintaining appropriate behavior, using judgment, and adapting to changes in a routine work setting.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

Disability program specialists are responsible for determining  disability and incapacity for ABD cash and referral to the HEN program.


Applications

  1. Refer ABD cash  applicants to the disability program specialist (DPS) when the person claims they have a physical or psychological impairment preventing them from working. These cases require  Disability  Decision by the DPS. If the person does not meet the disability criteria for ABD cash,  the disability program specialist will determine incapacity criteria for the HEN Referral program using the Sequential Evaluation Process (SEP).

 2.    Referrals to the disability program specialist include:

a.  Application date.

b.  Any medical records.

c.  Information about unpaid medical bills.

d.  Date of SSI application.

e.  Information about active medical coverage.

3.  The disability program specialist follows the Disability and Incapacity Evaluation Process in the Social Services Manual.

4.   Clients applying for or receiving long-term care services from Home and Community Services (HCS)  are assessed by social service specialists at those administrations. Refer ABD applicants to the HCS social service specialist for a functional assessment.


Disability Review Process

  1. When the Disability Program Specialist sends the Financial Services Specialist a DSHS 14-118 to terminate disability (ABD cash) due to a SSA denial or no longer meeting disability criteria:
    1. Send the person notice that ABD cash is terminated with the free form text provided by the DPS.
  2. When the Disability Program Specialist sends the Financial Services Specialist a DSHS 14-118 to terminate disability (ABD cash) due to no current medical evidence, the FSS:
    1. Sends the person notice that ABD cash is terminated for lack of current medical

Incapacity Review Process

  1. When the Disability Program Specialist sends the Financial Services Specialist a DSHS 14-118 to terminate HEN Referral due to no current medical evidence, the FSS:
    1. Sends the person notice that HEN Referral eligibility is terminated for lack of current medical evidence with the free form text provided by the DPS.
    2. If the FSS receives a DSHS 14-118(X) with a decision after a "no current medical" termination is issued, the FSS:
      1. Extends HEN Referral eligibility if approved and notifies the person that benefits are extended; or
      2. Issues a supplemental notice of termination with details from the new DSHS 14-118(X), if the benefits are terminated.

Terminations for failure to cooperate with treatment

  1. Terminate assistance when you receive the DSHS 14-118 Disability/Incapacity decision stating the person failed to satisfactorily participate in treatment or follow through with a Medicaid application.
  2. If the person reapplies prior to termination, refer the client to the disability program specialist.

Employment

  1. When an incapacitated person becomes employed, the FSS determines if the person remains financially eligible. If the person is no longer financially eligible, the FSS terminates assistance and informs the DPS of the termination.
  2. If the person is still financially eligible, the FSS contacts the disability program specialist to determine if the person is gainfully employed. The ISW will inform the FSS of their decision.
Modification Date: December 31, 2013