MEDICAL REDETERMINATION

Revised October 20, 2009

WORKER RESPONSIBILITIES

EX-PARTE REVIEW

Terminations where the disability process has been started but not yet established

If an ex-parte review of the record shows that an application for disability medical has already been made (either SOLQ or the SDX shows a claim has been filed OR the department has submitted a non-grant medical assistance (NGMA) request), allow medical to close under the original AU so that a valid termination letter is generated for the client.

Screen in and approve an S02 medical program and suppress the approval letter. Since the client is only approved pending a re-determination and has not been found 'eligible' for SSI-related medical, the department does not issue an award letter. If possible, add text to the termination letter (if this is a worker generated termination) or send a general correspondence letter indicating that medical is being continued until the re-determination process is complete.

Sample text: You can no longer medical benefits under the (TANF or family related) program. However, your record shows that you have applied to Social Security Administration (SSA) for disability benefits. Your medical coverage is being continued while SSA decides if you can receive disability payments. Please let us know as soon as SSA tells you their decision.

Approve the S02 by updating the DEM2 screen as in the example below. Code the approval source with an 'OI' (ODI waived) code and put the end date out for four months. Set a barcode tickler for four months to check on the status of the SSA/NGMA decision and document in the Remarks behind the DEM2 screen that the disability coding is a workaround to continue medical during a re-determination.

Code the DEM2 screen Disability/Incapacity fields

If income causes the case to trickle to spenddown, allow the medically needy with spenddown letter (20-01) to go out to the client. Add text to the MN letter to explain why CN medical coverage is not being continued.

Sample text: Your disability claim has been referred to the Division of Disability Determination Services (DDDS) to decide if you can receive medical based on a disabililty. However, your current income puts you over the standard for continuing coverage under the categorically needy program. You must incur the stated amount in medical expenses (spenddown) before medical coverage can begin. We will notify you when we receive a decision from DDDS on your claim.

EXAMPLE

Bill and his wife Carla receive TANF cash assistance with their two children. In August, Carla reports that they are separating and that Bill has moved out of the home. While he was on TANF, he had been working with his Workfirst social worker and had started the SSI application process. An ex-parte review of the case and the EJAS case notes indicate that Bill still claims a disability and that the SSI claim has been filed with Social Security Administration.

Screen in and approve an S02 medical program for Bill pending the outcome of the disability determination. Set a barcode tickler four months out to check on the status of the claim.

Terminations where the client claims to have a disability but there is no medical evidence

If an ex-parte review of the record shows that the client claims to have a disability but the department has not referred the client for a disability determination, CN medical needs to be continued while the department gathers supporting documentation from the client or the client's medical providers to consider for a NGMA referral. Allow the medical coverage to close under the original AU so that a valid termination letter is generated for the client.

Create a Request for Information letter (23-02) giving the client twenty days to provide the department with medical evidence to support a claim for disability. Set a barcode tickler to review for a response from the client.

Sample text: You can no longer get medical benefits under the (TANF or Family Related) program. Your record shows you claim to have a disability that prevents you from working, but we do not have any medical information in our records to support that claim. We are continuing your medical coverage while we determine if you can get medical benefits under a different program. Please provide any medical documents you have regarding your disability. If we do not hear from you by the due date above, we will not consider you for the disability medical program and your continued medical coverage will end.

Approve the S02 by updating the DEM2 screen as in the example below. Code the approval source with an 'OI' (ODI waived) code and put the end date out for four months.

If the client does not respond timely, remove the disability coding from the DEM2 screen and allow the CN medical to close giving advance and adequate notice to the client. Add freeform text to the termination letter:

Sample text: We asked for medical information so we could see if you can get disability medical benefits. We have not heard from you. If you are disabled, you may apply for disability benefits through the Social Security Administration (SSA) or apply for disability medical benefits from any of our offices.

If the client does respond, complete the referral for the NGMA to the department's social worker. Send a general correspondence (50-01) letter to the client to let them know that medical coverage will continue pending the decision on their disability claim. Add freeform text to the letter:

Sample text: Your disability claim has been referred to the Division of Disability Determination Services (DDDS). If more medical evidence is needed to make the determination, they will contact you. Your medical coverage will continue while this decision is being made.

Set a barcode tickler for four months to check on the status of the NGMA decision and document in the Remarks behind the DEM2 screen that the disability coding is a workaround in order to continue medical during a re-determination.

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