Purpose: Describes the procedures to obtain a determination of disability or blindness that enables adults not receiving other assistance to be related to Categorically Needy medical coverage (Medicaid).
Blind:A corrected central visual acuity of 20/200 or a 20 degree field of vision limitation.
Disability: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 12 months.
Disability Determination Services (DDS):The state entity that uses federal criteria to determine disability or blindness under an agreement with the Social Security Administration.
Non Grant Medical Assistance (NGMA):The process through which the department makes a disability determination for individuals who are not receiving Title II cash benefits based on disability.
Substantial Gainful Activity (SGA):A person who is earning more than a certain monthly amount (net of impairment-related work expenses) is ordinarily considered to be engaging in SGA.
WAC 182-512-0050
WAC 182-512-0050
Effective December 1, 2011
WAC 182-512-0050 SSI related medical -- General information
The department provides medical benefits under the categorically needy (CN) and medically needy (MN) SSI related programs for SSI related people, meaning those who meet at least one of the federal SSI program criteria as being:
Age sixty five or older;
Blind with:
Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or
A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees; or
Disabled:
"Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:
Can be expected to result in death; or
Has lasted or can be expected to last for a continuous period of not less than twelve months; or
In the case of a child seventeen years of age or younger, if the child suffers from any medically determinable physical or mental impairment of comparable severity.
Decisions on SSI related disability are subject to the authority of:
Federal statutes and regulations codified at 42 USC Sec 1382c and 20 CFR, parts 404 and 416, as amended; and
Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.
A denial of Title II or Title XVI federal benefits by SSA solely due to failure to meet the blindness or disability criteria is binding on the department unless the applicant's:
Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or
Medical condition has changed since the SSA denial was issued.
The department considers a client who meets the special requirements for SSI status under Sections 1619(a) or 1619(b) of the Social Security Act as an SSI recipient. Such a client is eligible for CN medical coverage under WAC 388-474-0005.
Individuals referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA Z Manual sections:
For HWD, program specific requirements in chapter 388-475 WAC.
Aliens who qualify for Medicaid benefits, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 388-438-0110.
The department pays for a client's medical care outside of Washington according to WAC 388-501-0180.
The department follows income and resource methodologies of the Supplemental Security Income (SSI) program defined in federal law when determining eligibility for SSI related medical or Medicare Cost Savings programs unless the department adopts rules that are less restrictive than those of the SSI program.
Refer to WAC 388-418-0025 for effects of changes on medical assistance for re-determination of eligibility.
An applicant who isn’t receiving a Title II cash payment based on a disability established by the Social Security Administration (SSA) may be eligible for SSI-related medical coverage through the Non Grant Medical Assistance (NGMA) process. DSHS staff submits a request to DDDS to determine whether a disability exists for the purposes of medical coverage only. If the person is claiming disability, but is aged or eligible for Medicaid through another program such as children’s medical, family medical, or ABD cash, a NGMA decision is only necessary if the client is applying for long term care services based on disability (such as COPES or DDD waiver).
If an applicant is eligible for SSI, SSDI, or ABD cash, DON’T refer for a NGMA decision. If a client has been denied for SSI or SSDI in the last year, DON’T refer for a NGMA unless the person provides proof that their medical condition has worsened or that they have a new disabling condition.
DDDS doesn’t consider the Substantial Gainful Activity (SGA) test when determining if a client meets the functional disability criteria. However, when the department receives a disability approval for an applicant, financial staff must take SGA into consideration when determining which medical program a client is eligible for and choose either SSI-related medical (S02, G03, C01) if income is under SGA or Healthcare for Workers with Disabilities (HWD) (S08) which waives the SGA test.
WORKER RESPONSIBILITIES
On receipt of request for a Medicaid decision:
Review the referral and Equal Access information and arrange for a telephone interview with the applicant or their representative if necessary.
Confirm the applicant is claiming blindness or disability. If the claim does not appear to meet SSI criteria, explains this to the applicant or representative and suggest the application be withdrawn. Obtain a withdrawal request if the applicant or representative agrees. Explain the following points about the determination process:
DDDS makes the determination of blindness or disability.
The standard of promptness date is 60 days, but additional time may be required.
The client has a right to request a hearing if they disagree with the decision and it will be the responsibility of DDDS to defend the decision.
The client is required to pay a monthly premium if earning over SGA and only eligible for coverage under the HWD program.
Review of Financial Information:
If the applicant isn’t working, and the applicant’s countable resources meet the following resource standards, complete a NGMA decision referral.
c.If the applicant is under age 65, working, and their income is over SGA standard or their resources exceed the standard described in 2.(a) above, forward the application to be completed by the HWD unit at:
i.For CSD staff:
·DMS CSO 157@HWD.
· HWD Voice message line (206) 272-2169
· HWD Toll Free line (800) 871-9275
·Address: DSHS – CSD Customer Service Center
PO BOX 11699
Tacoma, WA 98411-6699
ii.For HCS – send to the designated staff in your region.
Regional information phone numbers are:
Region 11
1-800-459-0421
Region 14
1-800-346-9257
Region 12
1-800-822-2097
Region 15
1-800-442-5129
Region 13
1-866-608-0836
Region 16
1-800-462-4957
3. Send the following forms to the applicant for completion and signature.
MedicalDisability Report and Decision, DSHS 14-144A.
4. Initiate a NGMA referral to DDDS through the Barcode NGMA application. See the Barcode Online Resources Guide for detailed instructions. Each referral contains the following:
5. Request retroactive approval if applicant client had a medical need in any of the three months before the month of application and meets financial eligibility for each of the retroactive months.
6.Medical Records. DDDS support staff or adjudicators obtain medical records directly from DMS for initial applications and reconsiderations. DON’T SEND PAPER MEDICAL RECORDS.
NOTE:
The Administrative Hearing Coordinator is still required to send a paper copy of an Administrative Hearings packet to the DDDS adjudicator.
Previous NGMA Packet. If the client is reapplying or requesting continued NGMA benefits:
a. Initiate a re-determination referral to DDDS through the Barcode NGMA application.
b.Document all actions in ACES.
c. Pend the application until a decision is received from DDDS. Document the reason for delays beyond 60 days from the date of application in ACES.
8. When DDDS returns the disability determination form 14-144:
a.If the client meets the disability criteria, open medical care in the appropriate category, based on income and resources per WAC 388-505-0110.
b. Enter the end date and the determination date on the DEM2 ACES screen, and send a request for a re-determination to DDDS at least 30 days prior to the review end date.
c. If the re-exam has been waived by DDDS, no end date is required.
d. If the applicant does not meet the disability criteria, consider the applicant for all other medical programs, or allow the client to provide new medical information to be forwarded to DDDS for reconsideration.
9. See Administrative Hearing chapter (Chapter 388-02 WAC) for hearing and reconsideration procedures.
