SSI Facilitation - General assistance - expedited Medicaid (GAX)
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SSI Facilitation - General assistance - expedited Medicaid (GAX)

Revised June 3, 2009

Purpose: Describe the process for determining and documenting eligibility for GA-X and expedited Medicaid.
WAC 388-448-0180How do we redetermine your eligibility when we decide you are eligible for general assistance expedited Medicaid (GAX)?

CLARIFIYING INFORMATION

  1. Persons eligible for GA-X receive full scope Medicaid coverage and state funded General Assistance (GA) cash benefits (WAC 388-448-0200 ).

  2. GA-X medical coverage may be approved with a back-dated eligibility date (WAC 388 416 0015) up to three months before the initial GA application date when:

a.      Unpaid medical bills exist,

b.      Medical evidence indicates the person was disabled for the dates of requested retroactive medical coverage, and

c.      The person meets all other eligibility factors including financial eligibility.

        3.   GA-X Contractors approve or deny GA-X.

   


NOTE:

GA-U recipients who have a Non Grant Medical (NGMA) or Social Security Disability medical approval (SSI in Early Input status) are eligible for GA-D Medicaid. Don't refer for GA-X .

  1. Persons receiving GA-X must have their medical eligibility reviewed at least every 12 months  using the procedures in the INCAPACITY section.
  2. Once the GA-X Contractor approves GA-X, no further referrals to a GAX contractor are needed to maintain eligibility for Medicaid coverage:

a. Through the SSA Post Appeals decision if the person is otherwise eligible for GA,

b. While the person participates in DASA chemical dependency treatment services, or

c. When GA is reopened within six months of termination


 


WAC 388-448-0180
WAC 388-448-0180

Effective May 1, 2004

WAC 388-448-0180 How do we redetermine your eligibility when we decide you are eligible for general assistance expedited Medicaid (GAX)?

  1. The maximum period of eligibility for GAX is twelve months before we must review additional medical evidence. If you remain on GAX at the end of the twelve-month period, we determine your eligibility using current medical evidence. 

  2. If your application for SSI is denied, and the denial is upheld by an SSI/SSA administrative hearing, we change your program eligibility from GAX to GAU if you do not provide proof you have filed an appeal with SSI/SSA appeals council within sixty days of your hearing decision.

  3. We change your program eligibility from GAX to GAU after the final SSI/SSA determination or if you fail to follow through with any part of the SSI/SSA appeals process.

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.

WORKER RESPONSIBILITIES

  1. Use DSHS 14-502 SSI hearing denial letter to inform the GAX recipient that they must provide proof of an appeal with the SSI Appeals Council in order to keep GAX Medicaid benefits.
  2. If GAX recipient doesn’t provide proof of a timely appeal:

a)      Do not refer for a non-grant medical determination. It has already been established the client does not meet disability criteria.

b)      Use DSHS 14-118, Incapacity Decision to notify financial services to change from GA-X to GA-U.

c)      Inform the financial worker of any potential medical eligibility information, such as a claim of pregnancy or intent to return to a family.

3.      Use DSHS 14-118, Incapacity Decision to notify financial services to change from GA-X to GA-U when:

a.      The final SSI/SSA determination is unfavorable.

b.      The client fails to follow through with the appeals process.

 

GA-X Contractors:

  1. Are licensed physicians and psychologists under contract with the Department of Social and Health Services - Community Services Division (CSD).
  2. Receive GA-X request referrals. The referrals may be sent to any GA-X Contractor appropriate to review the type of impairment as indicated on the GA-X Data screen in ICMS.
  3. Provide the following services:
    1. Certify when a person appears to meet SSI disability criteria,
    2. Authorize purchase of additional medical evidence and/or describe additional steps the facilitator may take when evidence is inadequate to approve GAX,
    3. Return the completed DSHS 14-333B, Certification for Medicaid: GA-X Decision to the CSO within five working days, and Consult with CSO staff regarding unclear cases.

NOTE:

To be complete the GAX Decision must include:
a. For approvals:
   i. The applicable SSI section listing number(s).
  ii. An explanation of the findings that support approval.
b. For denials:
  i. An explanation of why the person does not appear to meet SSI criteria.
 ii. Specific recommendations regarding additional medical evidence that would merit resubmission of the case.

WORKER RESPONSIBILITIES

  1. Determine the person meets GA incapacity criteria before the Social Worker requests GA-X.
  2. In cases where a person is approved for GA without medical documentation (e.g. released from psychiatric hospitalization with current treatment or by meeting Home and Community Services non-PEP approval criteria), obtain medical records and examinations as needed to support GA-X request.
  3. Use DSHS 14-332, Disability Assessment to determine when a person meets SSA disability criteria.
  4. Send a GA-X request at the time of the initial incapacity determination if the person appears to meet SSA disability criteria.

NOTE:

The Disability Assessment is available as “Step 8” of the PEP or as a stand-alone tool in ICMS.

5.   Review cases that have received GAU for 12 months or more and request GA-X  for cases that appear to meet SSI disability criteria.   

6.    If GA-X has not already been requested, request GAX within 5 working days of the date a person is referred for SSI facilitation services.

7.    The GA-X E-Referral request to a GA-X Contractor consists of the following documents:

a.       The DSHS 14-333A, Physician’s Certification for Medicaid,

b.       Attach the most recent medical records, and all relevant medical records that help to establish duration of an impairment or show treatment history. If the GA-X contractor needs more information, a request is sent to you. Send the additional medical information within 5 days through the addendum process in ICMS, and

c.      DSHS 14-050, Statement of Health, Education, and Employment.


See the Barcode Quick Guide to learn how send selected pages from a large file in the ECR:

Attaching DMS Documents to Letters


8.      Include in the GA-X request packet when available:

a.      Aging and Adult Services Comprehensive Assessment Reporting and Evaluation (CARE) assessment,

b.      Personal Observations,

c.      Activities of Daily Living reports

d.      Substance Abuse Treatment records,

e.        School records, especially when there is a history of special education, or

f.      Division of Vocational Rehabilitation records.


NOTE:

E-Referrals are limited to 50 pages.   If sending an E-Referral larger than 50 pages, send the first 50 pages with the E-Referral, then return to the GA-X referral screen in ICMS and send an addendum with the remaining documents.  Note in the comments on the original referral that an addendum is pending.   

WORKER RESPONSIBILITIES

GA-X APPROVAL

When the GA-X Contractor approves GA-X:

1.      Send a 14-118, Incapacity Decision, to make a program change from GA-U to GA-X. 

2.      The effective date of GA-X is the 1st of the Month where:

a.      GA-X is approved, or

b.      Retroactive GA-X coverage may be approved (up to three calendar months prior to the date of application).

GA-X Denial

When the GA-X Contractor denies GA-X:

1.      Inform the person of the denial by sending DSHS 14-343, SSI Facilitation Program Medicaid Decision Letter. 

2.      Request additional information if necessary.  See Resubmitting GA-X Requests below.  Only submit a second request if there is additional medical evidence that was not available in the first request.


Resubmitting GA-X Requests

1.      Re-send (resubmit) a new request packet only when:

a.      You have obtained additional information following a GA-X denial for insufficient information, or

b.      You get new medical information before the month of incapacity review.  The new medical information should show a more severe impairment or a new condition.

2.      When resubmitting a  request, re-send the medical information in the previous E-Referral along with new medical information and a new 14-333B. 

Links

Social Security

 

·        Social Security Administration

·        SSI

·        SSDI

·        Social Security Employment Programs

DSHS

·        GAU - Internal DSHS staff

·         ESA Policy Review Page (Blue Page)

DASA (ADATSA and Treatment Expansion)

 

·        Division of Alcohol and Substance Abuse (DASA)

·        DASA Treatment Expansion

·        Protocols for Treatment Expansion Clients

·        DASA Green Book (Directory of Certified Chemical Dependency Services in Washington State)

 

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Modification Date: June 3, 2009
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