Non-Grant Medical Assistance
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Non-Grant Medical Assistance


Revised April 29, 2013



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).

WAC 182-512-0050SSI related medical -- General information

DEFINITIONS

 

  • Aged: Age 65 or older.
  • 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.
  • Healthcare for Workers with Disabilities (HWD): A medical program that enables many people with disabilities to work and keep their health care.
  • 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 October 1, 2013

WAC 182-512-0050 SSI related medical -- General information



(1) The agency (which includes its designee for purposes of this chapter) provides health care coverage under the Washington apple health (WAH) 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:

(a) Age sixty-five or older;

(b) Blind with:

(i) Central visual acuity of 20/200 or less in the better eye with the use of a correcting lens; or

(ii) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees.

(c) Disabled:

(i) "Disabled" means unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment, which:

(A) Can be expected to result in death; or

(B) Has lasted or can be expected to last for a continuous period of not less than twelve months; or

(C) 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.

(ii) Decisions on SSI-related disability are subject to the authority of:

(A) Federal statutes and regulations codified at 42 U.S.C. Section 1382c and 20 C.F.R., parts 404 and 416, as amended; and

(B) Controlling federal court decisions, which define the OASDI and SSI disability standard and determination process.

(2) 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 agency unless the applicant's:

(a) Denial is under appeal in the reconsideration stage in SSA's administrative hearing process, or SSA's appeals council; or

(b) Medical condition has changed since the SSA denial was issued.

(3) The agency considers a person 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 person is eligible for WAH CN health care coverage under WAC 182-510-0001.

(4) Persons referred to in subsection (1) must also meet appropriate eligibility criteria found in the following WAC and EA-Z Manual sections:

(a) For all programs:

(i) WAC 182-506-0015, Medical assistance units;

(ii) WAC 182-504-0015, Categorically needy and WAC 182-504-0020, Medically needy certification periods;

(iii) Program specific requirements in chapter 182-512 WAC;

(iv) WAC 182-503-0050, Verification;

(v) WAC 182-503-0505, General eligibility requirements for medical programs;

(vi) WAC 182-503-0540, Assignment of rights and cooperation;

(vii) Chapter 182-516 WAC, Trusts, annuities and life estates.

(b) For LTC programs:

(i) Chapter 182-513 WAC, Long-term care services;

(ii) Chapter 182-515 WAC, Waiver services.

(c) For WAH MN, chapter 182-519 WAC, Spenddown;

(d) For WAH HWD, program specific requirements in chapter 182-511 WAC.

(5) Aliens who qualify for medicaid coverage, but are determined ineligible because of alien status may be eligible for programs as specified in WAC 182-507-0110.

(6) The agency pays for a person's medical care outside of Washington according to WAC 182-501-0180.

(7) The agency 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 agency adopts rules that are less restrictive than those of the SSI program.

(8) Refer to WAC 182-504-0125 for effects of changes on medical assistance for redetermination of eligibility.

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

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).

NGMA and DL-X flowchart


NOTE:

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

  1. On receipt of request for a Medicaid decision:
    1. Review the referral and Equal Access information and arrange for a telephone interview with the applicant or their representative if necessary.
    2. 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:
      1. DDDS makes the determination of blindness or disability.
      2. The standard of promptness date is 60 days, but additional time may be required.
      3. 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.
      4. The client is required to pay a monthly premium if earning over SGA and only eligible for coverage under the HWD program.
  2. Review of Financial Information:
    1. If the applicant isn’t working, and the applicant’s countable resources meet the following resource standards, complete a NGMA decision referral.

                                      i.        For SSI related categorically needy (CN) WAC 182-512-0010

        ·         One person $2,000.

·         Married couple $3,000.

                                    ii.        For SSI related medically needy (MN) WAC 388-478-0070

·          Add $50 for each additional family member.

                                   iii.        For Long Term Care programs see WAC 388-513-1350.


NOTE:

 If the client is over resources at the first of the month, and they aren’t working, they aren’t eligible for benefits in that month.   


b.    If the applicant is working, and the applicant’s income and resources meet the following requirements, complete a NGMA decision referral.

                                      i.        Gross earned income is below the SGA standard.

                                    ii.        Countable resources listed in section 2.a. above.

 

Non-Grant Medical Assistance (NGMA) - Examples

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.

Medical Disability Report and Decision, DSHS 14-144A.

Medical Information Release Form SSA 827.

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:

a.    Transmittal Summary, DSHS 14-144.

b.    Medical Disability Report and Decision, DSHS 14-144A.

c.    Medical Information Release Form SSA 827.

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.


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Modification Date: April 29, 2013