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”  is defined by the Social Security Administration for Supplemental Security Income (SSI) as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months with available treatment.
   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 disability services administration for a medical condition that is expected to last twelve 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.

WAC 182-508-0001 Medical assistance coverage for adults not covered under family medical programs.

(1)  An adult who does not meet the institutional status requirements as defined in WAC 388-513-1320  and who does not receive waiver services as described in Chapter 388-515 WAC is considered for categorically needy (CN) coverage under this chapter.  Individuals excluded from this section have rules applied to eligibility from Chapter 388-513 WAC.  Under this section an individual is eligible for CN coverage when the individual:

(a)  Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 182-503-0505; and

(b)  Has CN countable income and resources that do not exceed the income and resource standards in WAC WAC 182-512-0010; and

(c)  Is sixty-five years of age or older, or meets the blind and/or disability criteria of the federal SSI program.

(2)  An adult not meeting the conditions of subsection (1)(b) of this section is eligible for CN medical coverage if the individual:

(a)  Is a current beneficiary of Title II of the Social Security Act (SSA) benefits who:

(i)  Was a concurrent beneficiary of Title II and Supplemental Security Income (SSI) benefits;

(ii) Is ineligible for SSI benefits and/or state supplementary payments (SSP); and

(iii) Would be eligible for SSI benefits if certain cost-of-living (COLA) increases are deducted from the client's current Title II benefit amount;

(A) All Title II COLA increases under P.L. 94-566, section 503 received by the individual since their termination from SSI/SSP; and

(B) All Title II COLA increases received during the time period in subsection     (1)(d)(iii)(A) of this subsection by the individual's spouse or other financially responsible family member living in the same household.

(b)  Is an SSI beneficiary, no longer receiving a cash benefit due to employment, who meets the provisions of section 1619(b) of Title XVI of the SSA;

(c)  Is a currently disabled individual receiving widow's or widower's benefits under section 202(e) or (f) of the SSA if the disabled individual;

(i)  Was entitled to a monthly insurance benefit under Title II of the SSA for December 1983;

(ii)  Was entitled to and received a widow's or widower's benefit based on a disability under section 202(e) or (f) of the SSA for January 1984;

(iii) Became ineligible for SSI-SSP in the first month in which the increase provided under section 134 of P.L. 98-21 was paid to the individual;

(iv)  Has been continuously entitled to a widow's or widower's benefit under section 202(e) or (f) of the SSA;

(v)  Would be eligible for SSI/SSP benefits if the amount of that increase, and any subsequent COLA increases provided under section 215(i) of the SSA, were disregarded;

(vi)  Is fifty through fifty-nine years of age; and

(vii) Filed an application for Medicaid coverage before July 1, 1988.

(d) Was receiving, as of January 1, 1991, Title II disabled widow or widower benefits under section 202(e) or (f) of the SSA if the individual:

(i)  Is not eligible for the hospital insurance benefits under Medicare Part A;

(ii)  Received SSI/SSP payments in the month before receiving such Title II benefits;

(iii) Became ineligible for SSI/SSP due to receipt of or increase in such Title II benefits; and

(iv)  Would be eligible for SSI/SSP if the amount of such Title II benefits or increase in such Title II benefits under section 202(e) or (f) of the SSA, and any subsequent COLA increases provided under section 215(i) of the act were disregarded.

(e)  Is a disabled or blind individual receiving Title II Disabled Adult Childhood (DAC) benefits under section 202(d) of the SSA if the individual;

(i)  Is at least eighteen years old;

(ii)  Lost SSI/SSP benefits on or after July, 1988, due to receipt of or increase in DAC benefits; and

(iii) Would be eligible for SSI/SSP if the amount of the DAC benefits or increase under section 202(d) of the DAC and any subsequent COLA increases provided under section 215(i) of the SSA were disregarded.

(f)  Is an individual who:

(i) In August 1972, received:

(A)  Old age assistance (OAA);

(B)  Aid to blind (AB);

(C)  Aid to families with dependent children (AFDC);

(D)  Aid to the permanently and totally disabled (APTD); and

(ii)  Was entitled to or received retirement, survivors, and disability insurance (RSDI) benefits; or

(iii)  Is eligible for OAA, AB, AFDC, SSI or APTD solely because of the twenty percent increase in Social Security benefits under P.L. 92-336.

(3)  An adult who does not meet the institutional status requirement as defined in WAC 388-513-1320  and who does not receive waiver services as described in chapter 388-515 WAC is considered for medically needy (MN) coverage under this chapter.   Individuals excluded from this section have rules applied to eligibility from chapter 388-513 WAC.  Under this section an individual is eligible for MN coverage when the individual:

(a)  Meets citizenship/immigrant, residency, and Social Security number requirements as described in WAC 182-503-0505; and

(b)  Has MN countable income that does not exceed the income standards in WAC 182-512-0010, or meets the excess income spenddown requirements in WAC 388-519-0110; and

(c)  Meets the countable resource standards in WAC WAC 182-519-0050; and

(d)  Is sixty-five years of age or older or meets the blind and/or disability criteria of the federal SSI program.

(4)  MN coverage is available for an aged, blind, or disabled ineligible spouse of an SSI recipient.  See WAC 388-519-0100  for additional information.

(5)  An adult may be eligible for the alien emergency medical program as described in WAC 182-507-0110.

(6)  An adult is eligible for the aged, blind, disabled program when the individual:

(a)  Meets the requirements of the aged, blind, disabled program in WAC 388-400-0060 and 388-478-0033; or

(b)  Meets the SSI-related disability standards but cannot get the SSI cash grant due to immigration status or sponsor deeming issues.  Adults may be eligible for aged, blind, disabled cash benefits and CN medical coverage due to different sponsor deeming requirements.

(7)  An adult is eligible for the state-funded medical care services (MCS) program when the individual:

(a)  Meets the requirements under WAC 182-508-0005; or

(b) Meets the aged, blind, or disabled requirements of WAC 388-400-0060 and is a qualified alien as defined in WAC 388-424-0001 and is subject to the five-year bar as described in WAC 388-424-0006(3); or a nonqualified alien as defined in WAC 388-424-0001; or

(c)  Meets the requirements of the ADATSA program as described in WAC 182-508-0320 and WAC 182-508-0375.. 

(8)  An adult receiving MCS who resides in a county designated as a mandatory managed care plan county must enroll in a plan, pursuant to WAC 182-538-0063.